| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
441 |
440 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
200 |
194 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
318 |
316 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
26 |
$6K |
| D1120 |
Prophylaxis - child |
83 |
83 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
154 |
148 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
69 |
69 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$476.59 |
| D0230 |
Intraoral - periapical each additional radiographic image |
34 |
28 |
$299.70 |