| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
366 |
366 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
38 |
$5K |
| D1120 |
Prophylaxis - child |
26 |
26 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
593 |
592 |
$401.77 |
| D0274 |
Bitewings - four radiographic images |
208 |
208 |
$298.18 |
| D0220 |
Intraoral - periapical first radiographic image |
755 |
743 |
$145.06 |
| D1206 |
Topical application of fluoride varnish |
520 |
519 |
$54.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
709 |
528 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$0.00 |