| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
255 |
254 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
277 |
275 |
$6K |
| D1206 |
Topical application of fluoride varnish |
302 |
299 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
74 |
74 |
$958.26 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$855.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
70 |
70 |
$488.51 |
| D0274 |
Bitewings - four radiographic images |
17 |
17 |
$385.00 |