| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
338 |
337 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
393 |
392 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
227 |
219 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
71 |
69 |
$523.20 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$480.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$432.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$395.80 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$300.00 |