| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
740 |
725 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
137 |
137 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,274 |
636 |
$3K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
93 |
93 |
$1K |
| D0274 |
Bitewings - four radiographic images |
327 |
327 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
65 |
65 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$284.00 |
| D1999 |
|
94 |
87 |
$220.00 |
| D1120 |
Prophylaxis - child |
147 |
147 |
$192.50 |
| D0220 |
Intraoral - periapical first radiographic image |
91 |
85 |
$192.00 |
| D1206 |
Topical application of fluoride varnish |
29 |
29 |
$0.00 |