| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
55 |
50 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
81 |
$2K |
| D1110 |
Prophylaxis - adult |
73 |
73 |
$1K |
| D1120 |
Prophylaxis - child |
78 |
78 |
$924.00 |
| 99213 |
Office or other outpatient visit for the evaluation and management of an established patient, low complexity |
48 |
41 |
$885.47 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$783.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
89 |
88 |
$770.00 |
| D1351 |
Sealant - per tooth |
59 |
15 |
$590.00 |
| D0220 |
Intraoral - periapical first radiographic image |
221 |
215 |
$506.25 |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$333.00 |
| D0603 |
|
42 |
42 |
$300.00 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$286.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
67 |
65 |
$200.75 |
| D0140 |
Limited oral evaluation - problem focused |
78 |
76 |
$198.00 |
| D9910 |
|
30 |
30 |
$140.00 |
| D1320 |
|
12 |
12 |
$120.00 |
| D0270 |
|
45 |
44 |
$0.00 |