| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
405 |
405 |
$26K |
| D1120 |
Prophylaxis - child |
43 |
43 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
14 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
28 |
$416.97 |
| D0274 |
Bitewings - four radiographic images |
275 |
275 |
$154.78 |
| D0120 |
Periodic oral evaluation - established patient |
629 |
629 |
$66.94 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
12 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
215 |
215 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$0.00 |