| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
84 |
83 |
$4K |
| D1206 |
Topical application of fluoride varnish |
87 |
87 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
77 |
77 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$675.00 |
| D0220 |
Intraoral - periapical first radiographic image |
131 |
131 |
$645.00 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$630.00 |
| D0601 |
|
83 |
83 |
$460.00 |
| D0272 |
Bitewings - two radiographic images |
36 |
36 |
$360.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
106 |
106 |
$339.00 |
| D9920 |
|
12 |
12 |
$300.00 |
| D0602 |
|
12 |
12 |
$110.00 |