| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
614 |
611 |
$35K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
251 |
89 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
613 |
610 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
184 |
80 |
$15K |
| D0272 |
Bitewings - two radiographic images |
352 |
352 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
100 |
100 |
$4K |
| D0274 |
Bitewings - four radiographic images |
95 |
93 |
$4K |
| D2394 |
|
29 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$641.44 |
| D1208 |
Topical application of fluoride, excluding varnish |
31 |
31 |
$626.92 |