| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
235 |
235 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
274 |
274 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
132 |
132 |
$8K |
| D1110 |
Prophylaxis - adult |
111 |
111 |
$6K |
| D1206 |
Topical application of fluoride varnish |
184 |
184 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
253 |
248 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
12 |
$4K |
| D0274 |
Bitewings - four radiographic images |
70 |
70 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
147 |
139 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$667.00 |