| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
339 |
338 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
340 |
339 |
$6K |
| D0274 |
Bitewings - four radiographic images |
132 |
132 |
$3K |
| D9110 |
|
81 |
77 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
13 |
$900.00 |
| D0220 |
Intraoral - periapical first radiographic image |
120 |
118 |
$833.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$540.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$225.36 |