| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
128 |
128 |
$9K |
| D1330 |
|
184 |
184 |
$6K |
| D1110 |
Prophylaxis - adult |
74 |
74 |
$5K |
| D0274 |
Bitewings - four radiographic images |
128 |
128 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
182 |
182 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
14 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
59 |
55 |
$886.68 |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$462.24 |