| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
351 |
350 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
355 |
353 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
407 |
406 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
198 |
196 |
$9K |
| D0274 |
Bitewings - four radiographic images |
259 |
258 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
68 |
38 |
$5K |
| D1120 |
Prophylaxis - child |
107 |
105 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
833 |
434 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
75 |
74 |
$660.50 |