| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
243 |
227 |
$4K |
| D1206 |
Topical application of fluoride varnish |
243 |
227 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
226 |
207 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$449.20 |
| D0220 |
Intraoral - periapical first radiographic image |
143 |
114 |
$431.20 |
| D0274 |
Bitewings - four radiographic images |
46 |
44 |
$371.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
142 |
105 |
$315.40 |
| D0272 |
Bitewings - two radiographic images |
63 |
62 |
$206.80 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$63.15 |