| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
129 |
129 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
186 |
186 |
$5K |
| D1206 |
Topical application of fluoride varnish |
118 |
118 |
$3K |
| D0274 |
Bitewings - four radiographic images |
99 |
99 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
25 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
14 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
53 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
116 |
116 |
$733.71 |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$650.08 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$628.94 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
12 |
$350.30 |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
28 |
$192.64 |