| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
114 |
114 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
15 |
$3K |
| D1120 |
Prophylaxis - child |
68 |
68 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
65 |
65 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
14 |
$1K |
| D0274 |
Bitewings - four radiographic images |
38 |
38 |
$952.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$452.00 |