| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
432 |
432 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
142 |
29 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
472 |
471 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
504 |
504 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
12 |
$4K |
| D2335 |
|
21 |
12 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$585.00 |
| D0220 |
Intraoral - periapical first radiographic image |
20 |
18 |
$306.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$108.00 |