| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
791 |
791 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,220 |
1,220 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,419 |
1,419 |
$23K |
| D0274 |
Bitewings - four radiographic images |
522 |
522 |
$14K |
| D1120 |
Prophylaxis - child |
290 |
290 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
86 |
56 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
370 |
368 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
109 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
143 |
131 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$420.10 |