| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
373 |
373 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
86 |
$5K |
| D1120 |
Prophylaxis - child |
202 |
202 |
$4K |
| D1110 |
Prophylaxis - adult |
164 |
164 |
$3K |
| D0274 |
Bitewings - four radiographic images |
259 |
259 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
251 |
251 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
330 |
330 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
24 |
$947.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
106 |
106 |
$636.00 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$560.00 |
| D0272 |
Bitewings - two radiographic images |
44 |
44 |
$220.00 |