| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
200 |
196 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
107 |
55 |
$5K |
| D0274 |
Bitewings - four radiographic images |
134 |
133 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
29 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
155 |
152 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
29 |
$600.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$540.98 |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
57 |
$520.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
29 |
$462.24 |