| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
311 |
311 |
$14K |
| D1120 |
Prophylaxis - child |
315 |
315 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
403 |
402 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
39 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,341 |
347 |
$5K |
| D1206 |
Topical application of fluoride varnish |
496 |
495 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
52 |
52 |
$2K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
138 |
138 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$980.00 |