| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
222 |
222 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
24 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
157 |
156 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
157 |
157 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
260 |
252 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
19 |
$3K |
| D1110 |
Prophylaxis - adult |
68 |
68 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
61 |
60 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
97 |
97 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
29 |
29 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
161 |
113 |
$1K |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$220.00 |