| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
143 |
142 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
251 |
251 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
154 |
154 |
$2K |
| D1120 |
Prophylaxis - child |
49 |
49 |
$980.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
13 |
$861.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
14 |
$819.36 |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$360.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$339.55 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$320.00 |
| D0220 |
Intraoral - periapical first radiographic image |
57 |
57 |
$270.00 |