| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
792 |
792 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
236 |
210 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
802 |
802 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
936 |
896 |
$9K |
| D0274 |
Bitewings - four radiographic images |
288 |
288 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
716 |
708 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
144 |
144 |
$3K |
| D1120 |
Prophylaxis - child |
108 |
108 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
241 |
241 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
12 |
$269.96 |