| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
182 |
182 |
$760.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
22 |
22 |
$418.00 |
| D1206 |
Topical application of fluoride varnish |
110 |
110 |
$285.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$140.00 |
| D0220 |
Intraoral - periapical first radiographic image |
118 |
116 |
$117.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
85 |
70 |
$81.00 |
| D0120 |
Periodic oral evaluation - established patient |
28 |
28 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
13 |
$0.00 |