| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
594 |
590 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
596 |
595 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
788 |
762 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
384 |
383 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,205 |
1,168 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
156 |
152 |
$5K |
| D0274 |
Bitewings - four radiographic images |
216 |
216 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
14 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
58 |
$1K |
| D4355 |
|
24 |
15 |
$165.00 |
| D0603 |
|
32 |
26 |
$60.00 |