| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
252 |
250 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
170 |
169 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
182 |
181 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
159 |
158 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
15 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
14 |
$3K |
| D1120 |
Prophylaxis - child |
67 |
67 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
76 |
76 |
$2K |
| D0274 |
Bitewings - four radiographic images |
56 |
56 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
77 |
76 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
17 |
15 |
$510.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
66 |
62 |
$459.00 |
| D1330 |
|
88 |
87 |
$0.00 |