| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
54 |
52 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
90 |
90 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
36 |
36 |
$969.38 |
| D0230 |
Intraoral - periapical each additional radiographic image |
80 |
39 |
$842.54 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$703.68 |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
43 |
$498.80 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$411.86 |
| D0350 |
|
16 |
16 |
$255.48 |
| D0603 |
|
153 |
153 |
$0.00 |