| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
338 |
337 |
$12K |
| D1206 |
Topical application of fluoride varnish |
225 |
225 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
140 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
124 |
124 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
24 |
$2K |
| D0272 |
Bitewings - two radiographic images |
102 |
102 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
48 |
$554.37 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$452.88 |
| D1208 |
Topical application of fluoride, excluding varnish |
19 |
19 |
$215.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
15 |
$79.31 |