| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
236 |
236 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
213 |
213 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
141 |
141 |
$4K |
| D1206 |
Topical application of fluoride varnish |
87 |
87 |
$2K |
| D0274 |
Bitewings - four radiographic images |
159 |
159 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
14 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
197 |
197 |
$933.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
181 |
181 |
$897.00 |