| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
335 |
335 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
107 |
66 |
$7K |
| D1110 |
Prophylaxis - adult |
45 |
45 |
$2K |
| D1351 |
Sealant - per tooth |
100 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
113 |
113 |
$1K |
| D1206 |
Topical application of fluoride varnish |
43 |
43 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
259 |
258 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$1K |
| D1120 |
Prophylaxis - child |
24 |
24 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
143 |
143 |
$936.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$300.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$273.00 |