| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
371 |
370 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
488 |
488 |
$11K |
| D0274 |
Bitewings - four radiographic images |
226 |
226 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
456 |
451 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
54 |
$4K |
| D1120 |
Prophylaxis - child |
100 |
100 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
257 |
257 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
347 |
347 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$942.70 |
| D0272 |
Bitewings - two radiographic images |
43 |
43 |
$584.40 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$240.94 |
| D0140 |
Limited oral evaluation - problem focused |
31 |
30 |
$214.64 |
| D9430 |
|
13 |
12 |
$171.30 |