| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
427 |
387 |
$11K |
| D1110 |
Prophylaxis - adult |
151 |
134 |
$5K |
| D1120 |
Prophylaxis - child |
132 |
110 |
$5K |
| D0274 |
Bitewings - four radiographic images |
219 |
196 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
146 |
127 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$384.00 |
| D0140 |
Limited oral evaluation - problem focused |
21 |
13 |
$275.40 |
| D0220 |
Intraoral - periapical first radiographic image |
47 |
44 |
$275.22 |