| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
227 |
227 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
193 |
193 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
159 |
159 |
$4K |
| D0274 |
Bitewings - four radiographic images |
100 |
100 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$825.00 |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
112 |
$535.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
81 |
81 |
$342.00 |