| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2394 |
|
244 |
134 |
$41K |
| D1110 |
Prophylaxis - adult |
473 |
469 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
761 |
757 |
$19K |
| D1120 |
Prophylaxis - child |
430 |
430 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
444 |
444 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
13 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
161 |
160 |
$2K |
| D0274 |
Bitewings - four radiographic images |
51 |
51 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
32 |
32 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$959.00 |