| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
371 |
371 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
70 |
$11K |
| D1206 |
Topical application of fluoride varnish |
420 |
419 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
374 |
374 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
44 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
32 |
32 |
$775.00 |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
39 |
$663.00 |