| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
92 |
92 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
26 |
$3K |
| D1120 |
Prophylaxis - child |
27 |
27 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
337 |
337 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$526.08 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$397.73 |
| D0220 |
Intraoral - periapical first radiographic image |
141 |
139 |
$45.07 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$43.06 |
| D1208 |
Topical application of fluoride, excluding varnish |
109 |
109 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
71 |
24 |
$0.00 |