| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
491 |
491 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
446 |
446 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
182 |
182 |
$4K |
| D0274 |
Bitewings - four radiographic images |
161 |
161 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
322 |
317 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
15 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
199 |
198 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$676.08 |