| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
240 |
240 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
189 |
187 |
$4K |
| D0274 |
Bitewings - four radiographic images |
185 |
185 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
236 |
236 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
286 |
283 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
16 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
35 |
34 |
$700.00 |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$480.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$325.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$300.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$120.00 |