| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
315 |
315 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
148 |
147 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
286 |
286 |
$6K |
| D0274 |
Bitewings - four radiographic images |
168 |
168 |
$5K |
| D1330 |
|
374 |
374 |
$4K |
| D1310 |
|
371 |
371 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
90 |
89 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
153 |
149 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
36 |
36 |
$720.00 |