| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
564 |
564 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
548 |
548 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
708 |
708 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
365 |
362 |
$4K |
| D0272 |
Bitewings - two radiographic images |
213 |
213 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
411 |
338 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
27 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$2K |
| D1206 |
Topical application of fluoride varnish |
35 |
35 |
$894.96 |
| D9985 |
|
73 |
73 |
$0.00 |