| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
677 |
674 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
571 |
570 |
$6K |
| D0274 |
Bitewings - four radiographic images |
279 |
279 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
60 |
60 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
104 |
103 |
$634.43 |
| D1120 |
Prophylaxis - child |
29 |
29 |
$544.85 |
| D1208 |
Topical application of fluoride, excluding varnish |
29 |
29 |
$274.20 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$243.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
49 |
48 |
$147.25 |