| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
171 |
171 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
202 |
201 |
$13K |
| D0210 |
Intraoral - complete series of radiographic images |
99 |
99 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
815 |
148 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
258 |
257 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
14 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
69 |
68 |
$2K |
| D0274 |
Bitewings - four radiographic images |
58 |
57 |
$1K |
| D1206 |
Topical application of fluoride varnish |
41 |
41 |
$658.00 |