| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
164 |
164 |
$1K |
| D1110 |
Prophylaxis - adult |
148 |
148 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
18 |
$520.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
32 |
$475.20 |
| D0274 |
Bitewings - four radiographic images |
121 |
121 |
$453.65 |
| D0220 |
Intraoral - periapical first radiographic image |
176 |
174 |
$282.75 |
| D0230 |
Intraoral - periapical each additional radiographic image |
154 |
154 |
$260.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
37 |
37 |
$259.20 |
| D1120 |
Prophylaxis - child |
26 |
26 |
$172.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$58.50 |