| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
707 |
707 |
$31K |
| D1206 |
Topical application of fluoride varnish |
648 |
648 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
594 |
594 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
61 |
$6K |
| D0274 |
Bitewings - four radiographic images |
192 |
192 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
58 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
85 |
85 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
158 |
158 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
107 |
107 |
$482.16 |
| D0272 |
Bitewings - two radiographic images |
33 |
33 |
$359.28 |