| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
627 |
627 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
573 |
573 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
380 |
301 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
145 |
145 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
145 |
145 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
49 |
26 |
$3K |
| D0274 |
Bitewings - four radiographic images |
163 |
163 |
$2K |
| D1206 |
Topical application of fluoride varnish |
130 |
130 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
26 |
$2K |
| D1120 |
Prophylaxis - child |
56 |
56 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
85 |
$416.20 |