| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
319 |
319 |
$7K |
| D1110 |
Prophylaxis - adult |
164 |
164 |
$7K |
| D1120 |
Prophylaxis - child |
160 |
160 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
480 |
477 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
149 |
149 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
179 |
178 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
51 |
51 |
$2K |
| D0274 |
Bitewings - four radiographic images |
84 |
84 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
140 |
140 |
$2K |
| D1206 |
Topical application of fluoride varnish |
27 |
27 |
$769.50 |
| D0270 |
|
57 |
57 |
$685.10 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
13 |
$555.75 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$187.15 |