| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
82 |
81 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
17 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
19 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
41 |
41 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
83 |
80 |
$1K |
| D1120 |
Prophylaxis - child |
30 |
30 |
$1K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$768.32 |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
58 |
$703.36 |
| D0230 |
Intraoral - periapical each additional radiographic image |
58 |
58 |
$644.56 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$449.93 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$257.18 |
| D0603 |
|
266 |
255 |
$10.29 |