| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
628 |
628 |
$50K |
| D1120 |
Prophylaxis - child |
977 |
976 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
274 |
274 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
201 |
122 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,027 |
910 |
$13K |
| D0274 |
Bitewings - four radiographic images |
549 |
548 |
$12K |
| D1206 |
Topical application of fluoride varnish |
405 |
403 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$624.00 |
| D0350 |
|
38 |
25 |
$374.40 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$168.00 |