| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
208 |
208 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
286 |
285 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
86 |
86 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
118 |
118 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
15 |
$2K |
| D0274 |
Bitewings - four radiographic images |
60 |
60 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
27 |
27 |
$373.94 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$158.06 |