| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
308 |
306 |
$8K |
| D1110 |
Prophylaxis - adult |
431 |
424 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
433 |
423 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
178 |
175 |
$5K |
| D1120 |
Prophylaxis - child |
169 |
169 |
$3K |
| D0274 |
Bitewings - four radiographic images |
306 |
302 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
111 |
110 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,048 |
370 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
455 |
447 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
25 |
$1K |
| D1206 |
Topical application of fluoride varnish |
64 |
64 |
$945.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
81 |
81 |
$688.50 |
| D9920 |
|
15 |
15 |
$265.00 |
| D1330 |
|
568 |
561 |
$0.00 |