| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
228 |
228 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
212 |
212 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
162 |
162 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
45 |
44 |
$2K |
| D0274 |
Bitewings - four radiographic images |
116 |
116 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
183 |
181 |
$786.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
146 |
142 |
$645.00 |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$500.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$458.20 |