| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
221 |
221 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
173 |
173 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
76 |
76 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$1K |
| D1206 |
Topical application of fluoride varnish |
39 |
39 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
14 |
$982.80 |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$697.90 |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
82 |
$542.02 |
| D0230 |
Intraoral - periapical each additional radiographic image |
79 |
78 |
$358.40 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$312.96 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$299.43 |