| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
339 |
339 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
413 |
399 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
163 |
163 |
$3K |
| D0274 |
Bitewings - four radiographic images |
157 |
157 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
285 |
281 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
69 |
69 |
$579.60 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
36 |
36 |
$540.89 |
| D1320 |
|
69 |
69 |
$414.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$382.80 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
30 |
$242.13 |