| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
416 |
416 |
$9K |
| D1110 |
Prophylaxis - adult |
192 |
192 |
$8K |
| D1120 |
Prophylaxis - child |
110 |
110 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
291 |
291 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
190 |
190 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
40 |
$2K |
| D0274 |
Bitewings - four radiographic images |
82 |
82 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$845.25 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$826.25 |
| D0140 |
Limited oral evaluation - problem focused |
41 |
41 |
$509.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$168.40 |