| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
157 |
157 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
119 |
119 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
93 |
93 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
17 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
40 |
$1K |
| D0274 |
Bitewings - four radiographic images |
59 |
59 |
$672.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
99 |
94 |
$585.00 |
| D0220 |
Intraoral - periapical first radiographic image |
119 |
118 |
$498.00 |