| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
518 |
518 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
651 |
651 |
$20K |
| D0274 |
Bitewings - four radiographic images |
392 |
392 |
$5K |
| D1206 |
Topical application of fluoride varnish |
140 |
140 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
819 |
807 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
55 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
176 |
174 |
$2K |
| D1120 |
Prophylaxis - child |
37 |
37 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
411 |
411 |
$1K |