| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
197 |
196 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
110 |
49 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
236 |
236 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
232 |
232 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
53 |
20 |
$3K |
| D0274 |
Bitewings - four radiographic images |
172 |
172 |
$2K |
| D1120 |
Prophylaxis - child |
28 |
28 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$600.00 |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
43 |
$210.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
42 |
42 |
$138.00 |