| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
450 |
450 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
430 |
430 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
106 |
75 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
461 |
435 |
$5K |
| D0274 |
Bitewings - four radiographic images |
212 |
212 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
358 |
358 |
$3K |
| D1120 |
Prophylaxis - child |
43 |
43 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
14 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
100 |
100 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
14 |
$740.52 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
25 |
25 |
$561.00 |