| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
757 |
757 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
665 |
665 |
$12K |
| D2750 |
|
13 |
12 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
217 |
217 |
$5K |
| D0274 |
Bitewings - four radiographic images |
317 |
317 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
113 |
113 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
648 |
643 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
41 |
$3K |
| D1120 |
Prophylaxis - child |
80 |
80 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
24 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
89 |
88 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
459 |
458 |
$2K |
| D1206 |
Topical application of fluoride varnish |
36 |
36 |
$553.50 |