| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
335 |
334 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
468 |
462 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
442 |
440 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
354 |
354 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
398 |
395 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
107 |
107 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$363.24 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$301.60 |