| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
348 |
348 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
169 |
125 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
374 |
374 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
386 |
386 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
87 |
56 |
$6K |
| D1110 |
Prophylaxis - adult |
152 |
140 |
$5K |
| D0274 |
Bitewings - four radiographic images |
139 |
137 |
$4K |
| D0272 |
Bitewings - two radiographic images |
180 |
180 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
233 |
229 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
44 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
81 |
81 |
$784.80 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$769.65 |
| D0140 |
Limited oral evaluation - problem focused |
19 |
18 |
$581.80 |
| D0240 |
|
12 |
12 |
$142.49 |