| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
279 |
279 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
328 |
328 |
$7K |
| D0274 |
Bitewings - four radiographic images |
87 |
87 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
59 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
14 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
83 |
83 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
40 |
$458.48 |