| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
325 |
325 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
425 |
425 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
297 |
297 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
339 |
336 |
$2K |
| D0274 |
Bitewings - four radiographic images |
131 |
131 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
183 |
182 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$643.50 |