| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
79 |
79 |
$3K |
| D8670 |
Periodic orthodontic treatment visit |
13 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
58 |
58 |
$1K |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$945.00 |
| D0220 |
Intraoral - periapical first radiographic image |
84 |
83 |
$723.58 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$461.50 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$123.50 |