| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,641 |
1,640 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
2,341 |
2,341 |
$48K |
| D0274 |
Bitewings - four radiographic images |
655 |
655 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
163 |
102 |
$5K |
| D1120 |
Prophylaxis - child |
161 |
161 |
$4K |
| D1206 |
Topical application of fluoride varnish |
163 |
163 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
13 |
$806.40 |
| D0140 |
Limited oral evaluation - problem focused |
78 |
76 |
$650.30 |
| D0251 |
|
74 |
74 |
$532.80 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$139.26 |