| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
345 |
345 |
$11K |
| D0274 |
Bitewings - four radiographic images |
329 |
329 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
361 |
361 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
403 |
398 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
350 |
347 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
27 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$963.90 |
| D0140 |
Limited oral evaluation - problem focused |
46 |
46 |
$869.40 |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
43 |
$707.08 |
| D1330 |
|
74 |
74 |
$365.00 |
| D0602 |
|
28 |
28 |
$280.00 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$221.13 |