| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
232 |
219 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
221 |
208 |
$6K |
| D0274 |
Bitewings - four radiographic images |
128 |
118 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
25 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
65 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
55 |
27 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$602.70 |
| D1206 |
Topical application of fluoride varnish |
18 |
15 |
$354.25 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
13 |
$183.05 |