| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
366 |
366 |
$10K |
| D1110 |
Prophylaxis - adult |
188 |
188 |
$10K |
| D1120 |
Prophylaxis - child |
136 |
136 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
238 |
238 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
281 |
279 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
75 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
266 |
175 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
39 |
39 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$811.00 |