| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
245 |
140 |
$17K |
| D1110 |
Prophylaxis - adult |
225 |
225 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
230 |
230 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
447 |
440 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
40 |
40 |
$2K |
| D1206 |
Topical application of fluoride varnish |
41 |
41 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
37 |
37 |
$925.00 |
| D0140 |
Limited oral evaluation - problem focused |
68 |
67 |
$811.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
174 |
174 |
$603.00 |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$360.00 |
| D0270 |
|
14 |
14 |
$70.00 |