| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
66 |
66 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
54 |
54 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
12 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
58 |
58 |
$1K |
| D0274 |
Bitewings - four radiographic images |
46 |
46 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$560.00 |
| D0220 |
Intraoral - periapical first radiographic image |
53 |
51 |
$396.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
49 |
48 |
$352.00 |