| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
542 |
541 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
957 |
956 |
$11K |
| D0274 |
Bitewings - four radiographic images |
498 |
497 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
823 |
821 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
257 |
257 |
$1K |
| D1120 |
Prophylaxis - child |
58 |
58 |
$901.01 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$519.78 |
| D1208 |
Topical application of fluoride, excluding varnish |
85 |
85 |
$451.64 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$60.60 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$60.28 |