| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
181 |
180 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
259 |
258 |
$7K |
| D0274 |
Bitewings - four radiographic images |
189 |
189 |
$6K |
| D1206 |
Topical application of fluoride varnish |
268 |
268 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
142 |
142 |
$6K |
| D1120 |
Prophylaxis - child |
102 |
102 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
33 |
33 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$189.84 |