| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
483 |
483 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
316 |
316 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
782 |
740 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
424 |
403 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
26 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
103 |
103 |
$1K |
| D1120 |
Prophylaxis - child |
68 |
68 |
$1K |
| D0274 |
Bitewings - four radiographic images |
130 |
130 |
$981.48 |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$580.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$439.25 |