| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0210 |
Intraoral - complete series of radiographic images |
137 |
130 |
$7K |
| D1110 |
Prophylaxis - adult |
205 |
194 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
116 |
39 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
130 |
121 |
$5K |
| D1206 |
Topical application of fluoride varnish |
260 |
241 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
27 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
59 |
53 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
135 |
109 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
20 |
18 |
$565.44 |
| D1120 |
Prophylaxis - child |
15 |
13 |
$315.56 |
| D3120 |
|
72 |
16 |
$0.00 |