| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
391 |
391 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
293 |
276 |
$6K |
| D1110 |
Prophylaxis - adult |
264 |
262 |
$5K |
| D0603 |
|
315 |
315 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
507 |
507 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
52 |
52 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
15 |
$670.00 |
| D0220 |
Intraoral - periapical first radiographic image |
163 |
163 |
$644.00 |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$476.00 |
| D0120 |
Periodic oral evaluation - established patient |
14 |
14 |
$280.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
76 |
76 |
$255.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$238.00 |
| D0602 |
|
21 |
21 |
$210.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$108.00 |
| D1330 |
|
52 |
51 |
$0.00 |