| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
242 |
240 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
331 |
330 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
37 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
43 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
76 |
76 |
$3K |
| D0274 |
Bitewings - four radiographic images |
106 |
106 |
$1K |
| D1206 |
Topical application of fluoride varnish |
43 |
43 |
$937.50 |
| D0220 |
Intraoral - periapical first radiographic image |
184 |
182 |
$880.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
147 |
144 |
$879.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$585.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$350.00 |