| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
166 |
166 |
$10K |
| D1110 |
Prophylaxis - adult |
97 |
97 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
29 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
463 |
463 |
$951.93 |
| D0274 |
Bitewings - four radiographic images |
43 |
43 |
$430.36 |
| D1208 |
Topical application of fluoride, excluding varnish |
463 |
463 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
46 |
26 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
28 |
$0.00 |