| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
170 |
160 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
27 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
177 |
166 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
105 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
28 |
$2K |
| D1206 |
Topical application of fluoride varnish |
114 |
106 |
$2K |
| D0274 |
Bitewings - four radiographic images |
42 |
42 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
64 |
60 |
$831.47 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$519.52 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$416.64 |