| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
728 |
728 |
$20K |
| D1110 |
Prophylaxis - adult |
294 |
294 |
$15K |
| D1120 |
Prophylaxis - child |
222 |
222 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
48 |
$9K |
| D1206 |
Topical application of fluoride varnish |
296 |
296 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
245 |
241 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
98 |
98 |
$967.42 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$780.00 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$721.00 |