| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
62 |
62 |
$5K |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
43 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
28 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
159 |
155 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
437 |
199 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$1K |
| D1120 |
Prophylaxis - child |
27 |
26 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
56 |
$657.00 |
| D0350 |
|
67 |
28 |
$624.00 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$540.00 |