| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2335 |
|
48 |
31 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
199 |
199 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
105 |
105 |
$2K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
100 |
100 |
$975.62 |
| D0230 |
Intraoral - periapical each additional radiographic image |
40 |
40 |
$323.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$107.31 |