| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
145 |
145 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
26 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$739.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
26 |
26 |
$524.00 |
| D0274 |
Bitewings - four radiographic images |
19 |
18 |
$436.60 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
12 |
$411.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$369.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$180.60 |
| D1999 |
|
48 |
42 |
$0.00 |