| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
360 |
360 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
290 |
290 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
115 |
115 |
$510.00 |
| D0220 |
Intraoral - periapical first radiographic image |
99 |
99 |
$136.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
55 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
27 |
27 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
267 |
267 |
$0.00 |
| D1330 |
|
309 |
309 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
14 |
$0.00 |