| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
147 |
147 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
138 |
138 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
31 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
70 |
70 |
$2K |
| D1206 |
Topical application of fluoride varnish |
29 |
28 |
$843.75 |
| D0274 |
Bitewings - four radiographic images |
42 |
42 |
$497.00 |
| D0220 |
Intraoral - periapical first radiographic image |
81 |
80 |
$360.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$275.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
48 |
48 |
$159.00 |