| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
193 |
193 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
221 |
221 |
$6K |
| D1120 |
Prophylaxis - child |
196 |
196 |
$5K |
| D0274 |
Bitewings - four radiographic images |
164 |
164 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
168 |
168 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
172 |
172 |
$3K |
| D0272 |
Bitewings - two radiographic images |
84 |
84 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
16 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
38 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$873.46 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
30 |
$322.79 |