| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
723 |
720 |
$36K |
| D0210 |
Intraoral - complete series of radiographic images |
216 |
214 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
337 |
336 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
52 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
216 |
216 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
24 |
$2K |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$674.29 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$163.10 |
| D1320 |
|
14 |
14 |
$69.12 |