| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
471 |
470 |
$16K |
| D0274 |
Bitewings - four radiographic images |
386 |
386 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
382 |
380 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
181 |
181 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
307 |
243 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
290 |
290 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
34 |
34 |
$636.48 |