| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
536 |
535 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
510 |
509 |
$14K |
| D0274 |
Bitewings - four radiographic images |
211 |
211 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
379 |
374 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
123 |
123 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
27 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
24 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
185 |
140 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
74 |
$1K |
| D0602 |
|
168 |
168 |
$1K |
| D0601 |
|
162 |
162 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$455.00 |
| D1330 |
|
188 |
187 |
$0.00 |