| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
123 |
123 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
82 |
82 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
15 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
50 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
31 |
31 |
$775.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$540.00 |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
50 |
$390.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$168.00 |