| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
113 |
108 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
169 |
158 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
269 |
246 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
12 |
$3K |
| D1206 |
Topical application of fluoride varnish |
148 |
126 |
$3K |
| D1120 |
Prophylaxis - child |
94 |
83 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
36 |
$1K |
| D0274 |
Bitewings - four radiographic images |
87 |
73 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
142 |
124 |
$995.06 |
| D0230 |
Intraoral - periapical each additional radiographic image |
135 |
114 |
$286.77 |