| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
278 |
278 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
274 |
274 |
$7K |
| D0272 |
Bitewings - two radiographic images |
189 |
189 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
223 |
222 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
202 |
202 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
22 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
259 |
259 |
$1K |
| D1206 |
Topical application of fluoride varnish |
58 |
58 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$1K |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$737.46 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$347.04 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$269.28 |