| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
182 |
182 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
27 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
203 |
201 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
129 |
129 |
$5K |
| D1120 |
Prophylaxis - child |
130 |
130 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
121 |
121 |
$3K |
| D0274 |
Bitewings - four radiographic images |
74 |
74 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
37 |
$2K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$250.00 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
15 |
$231.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
12 |
$136.80 |