| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
203 |
203 |
$4K |
| D1110 |
Prophylaxis - adult |
101 |
101 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
27 |
$1K |
| D0274 |
Bitewings - four radiographic images |
125 |
124 |
$981.00 |
| D0220 |
Intraoral - periapical first radiographic image |
217 |
216 |
$836.00 |
| D1120 |
Prophylaxis - child |
40 |
40 |
$800.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
122 |
120 |
$660.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$651.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$235.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
38 |
38 |
$228.00 |