| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
344 |
344 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
280 |
280 |
$6K |
| D0274 |
Bitewings - four radiographic images |
261 |
260 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
147 |
147 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
304 |
299 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
31 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
51 |
$314.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$196.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$140.00 |