| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
287 |
287 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
287 |
287 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
145 |
145 |
$3K |
| D0274 |
Bitewings - four radiographic images |
282 |
282 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
426 |
423 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
374 |
373 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
26 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
37 |
$962.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
13 |
$532.00 |
| D1120 |
Prophylaxis - child |
26 |
26 |
$350.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$250.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$196.00 |