| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
227 |
227 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
247 |
247 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
24 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
88 |
88 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
150 |
148 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$2K |
| D1206 |
Topical application of fluoride varnish |
64 |
64 |
$2K |
| D1120 |
Prophylaxis - child |
39 |
39 |
$1K |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$433.89 |
| D0230 |
Intraoral - periapical each additional radiographic image |
47 |
44 |
$396.51 |