| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
167 |
133 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
104 |
93 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
18 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
47 |
47 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
14 |
$1K |
| D0274 |
Bitewings - four radiographic images |
97 |
86 |
$900.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$350.00 |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
47 |
$220.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
38 |
$210.00 |
| D1206 |
Topical application of fluoride varnish |
23 |
13 |
$187.50 |