| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
129 |
129 |
$6K |
| D1120 |
Prophylaxis - child |
160 |
160 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
194 |
194 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
80 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
178 |
177 |
$3K |
| D0272 |
Bitewings - two radiographic images |
185 |
185 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
12 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
31 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
50 |
$279.11 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$267.19 |
| D0230 |
Intraoral - periapical each additional radiographic image |
80 |
46 |
$186.30 |