| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
192 |
188 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
29 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
197 |
191 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
56 |
55 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$733.38 |
| D1120 |
Prophylaxis - child |
26 |
24 |
$439.79 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$439.22 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$141.80 |