| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
156 |
156 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
40 |
$3K |
| D1120 |
Prophylaxis - child |
14 |
14 |
$738.64 |
| D0274 |
Bitewings - four radiographic images |
318 |
318 |
$600.12 |
| D0120 |
Periodic oral evaluation - established patient |
431 |
431 |
$136.85 |
| D1208 |
Topical application of fluoride, excluding varnish |
68 |
68 |
$13.55 |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
38 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
52 |
$0.00 |