| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
548 |
548 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
508 |
508 |
$15K |
| D0274 |
Bitewings - four radiographic images |
249 |
249 |
$7K |
| D1120 |
Prophylaxis - child |
68 |
68 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
86 |
84 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
74 |
71 |
$952.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$350.00 |
| D0350 |
|
15 |
15 |
$210.00 |