| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
726 |
535 |
$19K |
| D1110 |
Prophylaxis - adult |
219 |
200 |
$7K |
| D0190 |
|
170 |
129 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
20 |
$2K |
| D0274 |
Bitewings - four radiographic images |
44 |
42 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
53 |
45 |
$819.27 |
| D0120 |
Periodic oral evaluation - established patient |
29 |
27 |
$592.55 |
| D1320 |
|
107 |
91 |
$383.04 |
| D0220 |
Intraoral - periapical first radiographic image |
22 |
16 |
$222.33 |