| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
169 |
163 |
$6K |
| D1206 |
Topical application of fluoride varnish |
179 |
173 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
180 |
180 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
17 |
$2K |
| D0272 |
Bitewings - two radiographic images |
83 |
83 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
88 |
88 |
$926.04 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$608.94 |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
45 |
$497.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
80 |
80 |
$448.45 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$272.28 |
| D1330 |
|
58 |
52 |
$0.00 |
| D1310 |
|
44 |
38 |
$0.00 |