| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
136 |
133 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$720.65 |
| D0120 |
Periodic oral evaluation - established patient |
57 |
57 |
$664.30 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$644.13 |
| D0274 |
Bitewings - four radiographic images |
27 |
25 |
$417.25 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
15 |
$274.19 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$255.35 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$162.57 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
12 |
$87.58 |