| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
176 |
176 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
24 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
149 |
149 |
$4K |
| D1110 |
Prophylaxis - adult |
69 |
69 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
58 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
37 |
$2K |
| D1206 |
Topical application of fluoride varnish |
99 |
99 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
80 |
80 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
51 |
51 |
$964.87 |
| D0230 |
Intraoral - periapical each additional radiographic image |
68 |
53 |
$536.19 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
14 |
$529.00 |