| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
736 |
734 |
$31K |
| D1110 |
Prophylaxis - adult |
755 |
749 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
109 |
63 |
$5K |
| D0274 |
Bitewings - four radiographic images |
240 |
240 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
86 |
86 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
132 |
132 |
$3K |
| D1120 |
Prophylaxis - child |
66 |
66 |
$2K |
| D2954 |
|
20 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
383 |
367 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
66 |
63 |
$2K |
| D1206 |
Topical application of fluoride varnish |
43 |
43 |
$890.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
177 |
176 |
$839.10 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
13 |
$800.00 |