| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
123 |
123 |
$6K |
| D1120 |
Prophylaxis - child |
150 |
150 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
199 |
199 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
205 |
201 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
102 |
102 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
55 |
55 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
44 |
$2K |
| D1206 |
Topical application of fluoride varnish |
68 |
68 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
187 |
117 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$626.39 |