| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
181 |
168 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
118 |
54 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
185 |
175 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
157 |
144 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
79 |
75 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
206 |
194 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
52 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
180 |
167 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
32 |
$452.80 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$412.20 |
| D0272 |
Bitewings - two radiographic images |
19 |
19 |
$178.60 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$0.00 |