| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
65 |
65 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
56 |
56 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
13 |
$900.00 |
| D0274 |
Bitewings - four radiographic images |
46 |
46 |
$644.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
96 |
94 |
$435.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
35 |
$351.20 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$280.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$88.00 |