| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
301 |
287 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
171 |
157 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
127 |
56 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
243 |
226 |
$6K |
| D0274 |
Bitewings - four radiographic images |
236 |
227 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
279 |
267 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
145 |
135 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
217 |
206 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
28 |
$2K |
| D1120 |
Prophylaxis - child |
128 |
121 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
93 |
86 |
$440.00 |