| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,108 |
1,105 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,303 |
1,302 |
$30K |
| D1120 |
Prophylaxis - child |
474 |
472 |
$16K |
| D1206 |
Topical application of fluoride varnish |
575 |
574 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
251 |
248 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
74 |
39 |
$8K |
| D0274 |
Bitewings - four radiographic images |
258 |
258 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$772.00 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$360.00 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$205.00 |