| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D5214 |
|
57 |
53 |
$49K |
| D1110 |
Prophylaxis - adult |
570 |
546 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
376 |
348 |
$21K |
| D5213 |
|
16 |
16 |
$17K |
| D0274 |
Bitewings - four radiographic images |
381 |
358 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
76 |
41 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
485 |
436 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
591 |
381 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
96 |
94 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
18 |
18 |
$765.00 |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$365.52 |