| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
373 |
373 |
$10K |
| D1110 |
Prophylaxis - adult |
198 |
198 |
$9K |
| D0274 |
Bitewings - four radiographic images |
87 |
87 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
28 |
$2K |
| D1120 |
Prophylaxis - child |
46 |
46 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
133 |
133 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
18 |
18 |
$321.60 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$155.50 |
| D1310 |
|
29 |
29 |
$0.00 |