| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
397 |
397 |
$4K |
| D1110 |
Prophylaxis - adult |
211 |
211 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
118 |
118 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
236 |
236 |
$678.00 |
| D0220 |
Intraoral - periapical first radiographic image |
317 |
315 |
$628.00 |
| D0140 |
Limited oral evaluation - problem focused |
73 |
73 |
$580.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
41 |
$560.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
49 |
$481.00 |
| D1120 |
Prophylaxis - child |
26 |
26 |
$280.00 |
| D0272 |
Bitewings - two radiographic images |
113 |
113 |
$225.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$45.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$42.00 |