| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
633 |
611 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
338 |
329 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
560 |
513 |
$6K |
| D1120 |
Prophylaxis - child |
183 |
173 |
$5K |
| D1110 |
Prophylaxis - adult |
130 |
126 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
123 |
121 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
25 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
14 |
$940.39 |
| D0230 |
Intraoral - periapical each additional radiographic image |
136 |
128 |
$909.52 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$778.58 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$269.91 |
| D0603 |
|
13 |
13 |
$0.00 |