| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
153 |
149 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
14 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
79 |
77 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
65 |
65 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
55 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$1K |
| D0274 |
Bitewings - four radiographic images |
98 |
96 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
166 |
162 |
$815.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$540.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
116 |
115 |
$471.00 |