| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
127 |
115 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
142 |
142 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
217 |
212 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
34 |
$2K |
| D1120 |
Prophylaxis - child |
124 |
124 |
$2K |
| D1110 |
Prophylaxis - adult |
91 |
90 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
25 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
73 |
72 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
67 |
67 |
$796.25 |
| D0220 |
Intraoral - periapical first radiographic image |
204 |
197 |
$615.00 |
| D0274 |
Bitewings - four radiographic images |
60 |
60 |
$540.00 |
| D0603 |
|
47 |
47 |
$470.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
124 |
123 |
$346.50 |