| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
46 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
162 |
162 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
90 |
$4K |
| D1110 |
Prophylaxis - adult |
78 |
76 |
$4K |
| D1120 |
Prophylaxis - child |
51 |
51 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
75 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
150 |
140 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
152 |
148 |
$720.00 |
| D0274 |
Bitewings - four radiographic images |
56 |
53 |
$598.00 |
| D0120 |
Periodic oral evaluation - established patient |
17 |
17 |
$510.00 |
| D9110 |
|
12 |
12 |
$396.00 |
| D0601 |
|
14 |
14 |
$120.00 |