| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
207 |
207 |
$7K |
| D1120 |
Prophylaxis - child |
121 |
121 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
212 |
212 |
$5K |
| D1110 |
Prophylaxis - adult |
103 |
102 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
26 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
299 |
299 |
$1K |
| D0274 |
Bitewings - four radiographic images |
113 |
113 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
267 |
267 |
$830.10 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$259.50 |