| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
112 |
112 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
61 |
61 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
78 |
78 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
122 |
122 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
13 |
$3K |
| D1110 |
Prophylaxis - adult |
51 |
51 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
84 |
84 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
138 |
50 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
58 |
$952.88 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$444.18 |