| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
335 |
335 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
208 |
208 |
$4K |
| D1206 |
Topical application of fluoride varnish |
191 |
191 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
83 |
83 |
$1K |
| D1110 |
Prophylaxis - adult |
64 |
64 |
$1K |
| D0602 |
|
73 |
73 |
$730.00 |
| D0220 |
Intraoral - periapical first radiographic image |
150 |
147 |
$528.12 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$518.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
93 |
93 |
$474.68 |
| D0230 |
Intraoral - periapical each additional radiographic image |
37 |
37 |
$108.00 |