| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
187 |
187 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
162 |
162 |
$4K |
| D1206 |
Topical application of fluoride varnish |
129 |
129 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
14 |
$1K |
| D0274 |
Bitewings - four radiographic images |
77 |
77 |
$912.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
31 |
31 |
$775.00 |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$765.00 |
| D0220 |
Intraoral - periapical first radiographic image |
141 |
141 |
$645.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
102 |
102 |
$549.00 |