| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
64 |
64 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
62 |
62 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
64 |
64 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
22 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
19 |
$1K |
| D0274 |
Bitewings - four radiographic images |
51 |
51 |
$760.50 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
34 |
34 |
$715.70 |
| D0220 |
Intraoral - periapical first radiographic image |
96 |
96 |
$532.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
91 |
90 |
$448.40 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$287.80 |