| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,018 |
1,018 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
986 |
986 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
378 |
378 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
842 |
839 |
$6K |
| D0274 |
Bitewings - four radiographic images |
536 |
536 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
989 |
973 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
37 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
63 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
64 |
$938.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$912.00 |
| D1206 |
Topical application of fluoride varnish |
48 |
48 |
$720.00 |
| D0272 |
Bitewings - two radiographic images |
105 |
105 |
$525.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$182.00 |
| D5421 |
|
13 |
13 |
$117.00 |