| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
559 |
559 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
863 |
862 |
$19K |
| D1206 |
Topical application of fluoride varnish |
1,012 |
1,011 |
$16K |
| D0274 |
Bitewings - four radiographic images |
236 |
236 |
$6K |
| D1120 |
Prophylaxis - child |
120 |
120 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
176 |
175 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
20 |
20 |
$806.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
27 |
27 |
$248.23 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$246.22 |