| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
390 |
390 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
92 |
63 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
498 |
472 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
230 |
230 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
197 |
194 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
412 |
401 |
$3K |
| D0274 |
Bitewings - four radiographic images |
131 |
131 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
89 |
89 |
$2K |
| D1320 |
|
120 |
120 |
$952.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
13 |
$500.00 |
| D0140 |
Limited oral evaluation - problem focused |
54 |
52 |
$442.10 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$177.90 |