| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
408 |
405 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
167 |
153 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
348 |
346 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
155 |
155 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
103 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
26 |
$2K |
| D1120 |
Prophylaxis - child |
38 |
38 |
$1K |
| D0272 |
Bitewings - two radiographic images |
71 |
71 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
105 |
$821.00 |