| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
114 |
111 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
147 |
147 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
194 |
193 |
$1K |
| D0274 |
Bitewings - four radiographic images |
59 |
59 |
$936.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
33 |
33 |
$825.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
119 |
119 |
$639.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$540.00 |