| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
45 |
45 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
48 |
48 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$460.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
80 |
34 |
$375.00 |
| D0220 |
Intraoral - periapical first radiographic image |
61 |
61 |
$292.00 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
13 |
$222.04 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$180.00 |