| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
66 |
66 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
59 |
$2K |
| D1110 |
Prophylaxis - adult |
36 |
36 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
77 |
77 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$808.57 |
| D0274 |
Bitewings - four radiographic images |
32 |
32 |
$749.04 |
| D1206 |
Topical application of fluoride varnish |
157 |
157 |
$343.35 |
| D0272 |
Bitewings - two radiographic images |
56 |
56 |
$23.79 |
| D1330 |
|
139 |
139 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$0.00 |