| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
314 |
312 |
$6K |
| D1110 |
Prophylaxis - adult |
189 |
188 |
$6K |
| D1206 |
Topical application of fluoride varnish |
265 |
263 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
97 |
$2K |
| D1120 |
Prophylaxis - child |
89 |
89 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
17 |
$2K |
| D0274 |
Bitewings - four radiographic images |
92 |
92 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
13 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$672.88 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$244.85 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$90.93 |