| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
516 |
516 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
346 |
346 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
201 |
201 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
237 |
237 |
$5K |
| D0274 |
Bitewings - four radiographic images |
275 |
275 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
412 |
410 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
509 |
498 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
24 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
57 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
14 |
$845.25 |
| D1120 |
Prophylaxis - child |
15 |
15 |
$402.50 |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$276.00 |