| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,626 |
2,581 |
$9K |
| D1110 |
Prophylaxis - adult |
1,819 |
1,797 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
715 |
508 |
$8K |
| D0330 |
Panoramic radiographic image |
1,808 |
1,799 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,581 |
1,573 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
247 |
175 |
$4K |
| D2750 |
|
18 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
1,090 |
1,050 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
302 |
297 |
$830.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
31 |
$580.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$52.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
26 |
$20.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$10.00 |
| D0270 |
|
14 |
12 |
$3.25 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$0.00 |