| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
937 |
929 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
141 |
80 |
$7K |
| D0274 |
Bitewings - four radiographic images |
298 |
298 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
94 |
92 |
$1K |
| D1120 |
Prophylaxis - child |
13 |
13 |
$666.05 |
| D1206 |
Topical application of fluoride varnish |
349 |
347 |
$282.76 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$172.98 |
| D0120 |
Periodic oral evaluation - established patient |
1,075 |
1,072 |
$143.03 |
| D0220 |
Intraoral - periapical first radiographic image |
410 |
396 |
$26.11 |
| D0230 |
Intraoral - periapical each additional radiographic image |
132 |
72 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
149 |
147 |
$-98.29 |