| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
151 |
151 |
$4K |
| D1110 |
Prophylaxis - adult |
79 |
79 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
189 |
189 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
218 |
217 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
18 |
18 |
$810.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
19 |
19 |
$475.00 |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$328.00 |