| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
364 |
249 |
$195K |
| D1110 |
Prophylaxis - adult |
1,910 |
1,910 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
2,176 |
2,176 |
$57K |
| D0274 |
Bitewings - four radiographic images |
907 |
907 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,573 |
1,554 |
$20K |
| D1120 |
Prophylaxis - child |
456 |
456 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
208 |
145 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,035 |
1,027 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
581 |
565 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
223 |
223 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
41 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
79 |
78 |
$2K |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$420.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$336.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$223.72 |
| D1999 |
|
32 |
27 |
$0.00 |