| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
178 |
178 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
226 |
226 |
$6K |
| D1206 |
Topical application of fluoride varnish |
170 |
170 |
$4K |
| D0274 |
Bitewings - four radiographic images |
84 |
84 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
210 |
203 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
172 |
120 |
$2K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$550.95 |
| D0240 |
|
22 |
12 |
$484.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$348.90 |