| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
681 |
681 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
304 |
180 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
509 |
509 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
111 |
84 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
128 |
81 |
$7K |
| D0274 |
Bitewings - four radiographic images |
335 |
335 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
150 |
150 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
498 |
493 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
383 |
382 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$1K |
| D1120 |
Prophylaxis - child |
19 |
19 |
$855.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
31 |
31 |
$775.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$585.00 |