| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
62 |
62 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
14 |
$2K |
| D1206 |
Topical application of fluoride varnish |
61 |
61 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
46 |
46 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
16 |
$975.00 |
| D0272 |
Bitewings - two radiographic images |
34 |
34 |
$812.00 |