| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
473 |
468 |
$2K |
| D1120 |
Prophylaxis - child |
425 |
425 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
553 |
553 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
88 |
88 |
$986.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
424 |
424 |
$893.00 |
| D0220 |
Intraoral - periapical first radiographic image |
589 |
578 |
$845.00 |
| D0140 |
Limited oral evaluation - problem focused |
172 |
170 |
$805.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
105 |
$532.00 |
| D1206 |
Topical application of fluoride varnish |
442 |
441 |
$475.00 |
| D0274 |
Bitewings - four radiographic images |
227 |
227 |
$464.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
485 |
255 |
$414.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
100 |
78 |
$284.00 |
| D0603 |
|
197 |
197 |
$231.00 |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$160.00 |
| D0602 |
|
30 |
30 |
$11.00 |
| D1330 |
|
532 |
532 |
$0.00 |