| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
371 |
371 |
$14K |
| D1206 |
Topical application of fluoride varnish |
404 |
404 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
286 |
286 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
145 |
145 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
206 |
125 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$350.00 |