| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
474 |
464 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
326 |
190 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
762 |
744 |
$17K |
| D1110 |
Prophylaxis - adult |
386 |
377 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
219 |
129 |
$9K |
| D0274 |
Bitewings - four radiographic images |
359 |
352 |
$9K |
| D1206 |
Topical application of fluoride varnish |
472 |
462 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
104 |
102 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
181 |
179 |
$3K |
| D0272 |
Bitewings - two radiographic images |
90 |
88 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
18 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
24 |
$678.15 |
| D0220 |
Intraoral - periapical first radiographic image |
72 |
69 |
$542.24 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
16 |
$140.16 |
| D9986 |
|
141 |
121 |
$12.00 |