| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
136 |
131 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
171 |
167 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
81 |
43 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
99 |
94 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
93 |
90 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
28 |
$2K |
| D0274 |
Bitewings - four radiographic images |
93 |
90 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
36 |
33 |
$996.59 |
| D0220 |
Intraoral - periapical first radiographic image |
157 |
144 |
$892.35 |
| D1110 |
Prophylaxis - adult |
16 |
15 |
$677.32 |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$600.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
129 |
117 |
$600.55 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$286.80 |