| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
421 |
420 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
353 |
351 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
117 |
76 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
120 |
120 |
$5K |
| D0274 |
Bitewings - four radiographic images |
130 |
130 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
170 |
170 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
92 |
92 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
138 |
137 |
$1K |
| D1330 |
|
168 |
168 |
$345.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$331.77 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$228.52 |