| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
209 |
204 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
251 |
244 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
86 |
$5K |
| D1206 |
Topical application of fluoride varnish |
163 |
160 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
13 |
$3K |
| D0274 |
Bitewings - four radiographic images |
90 |
90 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
17 |
16 |
$803.42 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$165.48 |
| D1330 |
|
14 |
14 |
$84.00 |