| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
254 |
252 |
$8K |
| D0274 |
Bitewings - four radiographic images |
242 |
240 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
218 |
217 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
307 |
290 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
28 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
256 |
254 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
17 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
70 |
64 |
$1K |
| D1206 |
Topical application of fluoride varnish |
36 |
36 |
$612.36 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$585.90 |
| D1330 |
|
82 |
82 |
$405.00 |
| D0602 |
|
35 |
35 |
$350.00 |
| D0270 |
|
12 |
12 |
$90.72 |