| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,430 |
1,430 |
$31K |
| D1110 |
Prophylaxis - adult |
997 |
997 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
516 |
516 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,634 |
1,605 |
$9K |
| D0274 |
Bitewings - four radiographic images |
666 |
666 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
250 |
250 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,337 |
1,326 |
$7K |
| D1120 |
Prophylaxis - child |
359 |
359 |
$7K |
| D1206 |
Topical application of fluoride varnish |
361 |
361 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
43 |
$4K |
| D2950 |
|
17 |
14 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$263.90 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$104.00 |
| D1999 |
|
862 |
736 |
$0.00 |