| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
387 |
387 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
422 |
422 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
53 |
24 |
$3K |
| D0274 |
Bitewings - four radiographic images |
121 |
121 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
291 |
288 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
305 |
234 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
150 |
150 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$1K |
| D1120 |
Prophylaxis - child |
12 |
12 |
$0.00 |
| D9920 |
|
28 |
25 |
$0.00 |