| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
276 |
276 |
$15K |
| D1120 |
Prophylaxis - child |
70 |
70 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
220 |
220 |
$451.97 |
| D0120 |
Periodic oral evaluation - established patient |
839 |
835 |
$422.28 |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
38 |
$62.48 |
| D1208 |
Topical application of fluoride, excluding varnish |
322 |
321 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$0.00 |