| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
179 |
178 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
315 |
315 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
186 |
181 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
59 |
59 |
$1K |
| D1206 |
Topical application of fluoride varnish |
38 |
38 |
$970.42 |
| D0230 |
Intraoral - periapical each additional radiographic image |
87 |
82 |
$743.25 |
| D1120 |
Prophylaxis - child |
17 |
17 |
$679.92 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$386.58 |