| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
113 |
113 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
17 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
110 |
107 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
89 |
89 |
$2K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
32 |
$1K |
| D1206 |
Topical application of fluoride varnish |
32 |
32 |
$725.00 |
| D0220 |
Intraoral - periapical first radiographic image |
49 |
49 |
$690.00 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$481.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
47 |
47 |
$396.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$310.00 |