| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
222 |
221 |
$20K |
| D1120 |
Prophylaxis - child |
65 |
65 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
13 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
379 |
378 |
$91.18 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$60.94 |
| D0230 |
Intraoral - periapical each additional radiographic image |
168 |
104 |
$17.41 |
| D0220 |
Intraoral - periapical first radiographic image |
262 |
244 |
$9.22 |
| D1208 |
Topical application of fluoride, excluding varnish |
441 |
440 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
115 |
114 |
$0.00 |