| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
531 |
525 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
341 |
205 |
$24K |
| D1120 |
Prophylaxis - child |
154 |
154 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
24 |
$1K |
| D1206 |
Topical application of fluoride varnish |
219 |
218 |
$204.60 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$163.41 |
| D0274 |
Bitewings - four radiographic images |
149 |
149 |
$120.94 |
| D0120 |
Periodic oral evaluation - established patient |
979 |
974 |
$32.04 |
| D1208 |
Topical application of fluoride, excluding varnish |
52 |
52 |
$27.10 |
| D0220 |
Intraoral - periapical first radiographic image |
64 |
63 |
$9.22 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
14 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$0.00 |