| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
292 |
292 |
$8K |
| D1120 |
Prophylaxis - child |
237 |
237 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
416 |
416 |
$7K |
| D1110 |
Prophylaxis - adult |
138 |
138 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
48 |
27 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
87 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
44 |
44 |
$880.24 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$165.86 |