| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
86 |
86 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
103 |
103 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
94 |
94 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
32 |
32 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
33 |
33 |
$1K |
| D0274 |
Bitewings - four radiographic images |
35 |
35 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
66 |
65 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
67 |
57 |
$551.60 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$339.00 |