| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
725 |
725 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
234 |
129 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
315 |
315 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
516 |
516 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
134 |
74 |
$12K |
| D0274 |
Bitewings - four radiographic images |
401 |
401 |
$10K |
| D2394 |
|
76 |
34 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
325 |
325 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
577 |
574 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
177 |
177 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
95 |
95 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
75 |
74 |
$966.70 |