| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
489 |
489 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
551 |
551 |
$3K |
| D0603 |
|
290 |
290 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
123 |
123 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
262 |
261 |
$988.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
16 |
$880.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
194 |
194 |
$645.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$540.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$200.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$75.00 |
| D1310 |
|
43 |
42 |
$0.00 |
| D1330 |
|
41 |
41 |
$0.00 |
| D9993 |
|
28 |
28 |
$0.00 |