| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
156 |
156 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
232 |
232 |
$5K |
| D0274 |
Bitewings - four radiographic images |
195 |
195 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
45 |
$4K |
| D1120 |
Prophylaxis - child |
104 |
104 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
194 |
194 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
142 |
142 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
27 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
58 |
$716.50 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$476.62 |