| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
151 |
151 |
$7K |
| D1206 |
Topical application of fluoride varnish |
113 |
113 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
140 |
139 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
37 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
30 |
$3K |
| D0274 |
Bitewings - four radiographic images |
61 |
61 |
$660.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
93 |
93 |
$645.00 |
| D0220 |
Intraoral - periapical first radiographic image |
104 |
104 |
$615.00 |