| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
420 |
420 |
$9K |
| D1110 |
Prophylaxis - adult |
194 |
194 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
174 |
169 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
316 |
313 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
217 |
199 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
583 |
565 |
$4K |
| D1206 |
Topical application of fluoride varnish |
225 |
225 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
36 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,508 |
438 |
$2K |
| D1999 |
|
138 |
121 |
$2K |
| D0274 |
Bitewings - four radiographic images |
184 |
183 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
46 |
46 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$927.96 |
| D1120 |
Prophylaxis - child |
38 |
38 |
$873.24 |