| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
382 |
382 |
$13K |
| D0274 |
Bitewings - four radiographic images |
360 |
360 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
452 |
452 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
56 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
162 |
162 |
$3K |
| D1120 |
Prophylaxis - child |
50 |
50 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
115 |
110 |
$865.20 |
| D0140 |
Limited oral evaluation - problem focused |
18 |
17 |
$176.00 |