| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
480 |
473 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
466 |
454 |
$24K |
| D1110 |
Prophylaxis - adult |
618 |
606 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
401 |
393 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
42 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
662 |
580 |
$3K |
| D1206 |
Topical application of fluoride varnish |
344 |
341 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
26 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
70 |
67 |
$996.69 |
| D0220 |
Intraoral - periapical first radiographic image |
653 |
639 |
$803.02 |
| D0274 |
Bitewings - four radiographic images |
336 |
335 |
$575.00 |
| D1120 |
Prophylaxis - child |
99 |
98 |
$481.00 |
| D1330 |
|
215 |
214 |
$327.38 |