| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
228 |
228 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
274 |
274 |
$8K |
| D1120 |
Prophylaxis - child |
134 |
134 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
30 |
$3K |
| D0274 |
Bitewings - four radiographic images |
68 |
68 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
146 |
146 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
26 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$1K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$250.90 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$206.60 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$185.20 |