| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
178 |
172 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
188 |
181 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
45 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
134 |
130 |
$3K |
| D0274 |
Bitewings - four radiographic images |
102 |
98 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
246 |
233 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
65 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
77 |
71 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
13 |
$709.55 |
| D0230 |
Intraoral - periapical each additional radiographic image |
187 |
178 |
$687.80 |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$584.20 |
| D0272 |
Bitewings - two radiographic images |
50 |
48 |
$413.60 |
| D0270 |
|
15 |
14 |
$72.80 |