| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
14 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
107 |
104 |
$3K |
| D1120 |
Prophylaxis - child |
60 |
60 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
119 |
116 |
$2K |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
133 |
127 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
114 |
110 |
$1K |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$981.96 |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$931.86 |
| D0603 |
|
170 |
164 |
$0.00 |