| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
202 |
202 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
163 |
163 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
63 |
$4K |
| D0272 |
Bitewings - two radiographic images |
103 |
103 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
156 |
156 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
68 |
68 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
82 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
38 |
$475.04 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$446.52 |