| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
260 |
251 |
$10K |
| D1206 |
Topical application of fluoride varnish |
250 |
242 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
224 |
216 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
32 |
$2K |
| D0274 |
Bitewings - four radiographic images |
45 |
44 |
$709.80 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$586.15 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
25 |
$526.25 |
| D0220 |
Intraoral - periapical first radiographic image |
46 |
45 |
$246.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
16 |
$91.20 |