| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
122 |
122 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
84 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
58 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
161 |
161 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
67 |
67 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
235 |
234 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
23 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
37 |
$792.50 |
| D0274 |
Bitewings - four radiographic images |
74 |
74 |
$707.60 |
| D1120 |
Prophylaxis - child |
35 |
35 |
$700.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
15 |
$665.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$630.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
111 |
111 |
$395.10 |