| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
75 |
74 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
66 |
66 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
34 |
34 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D9430 |
|
29 |
27 |
$812.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
67 |
66 |
$598.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
162 |
57 |
$483.00 |
| D0350 |
|
79 |
38 |
$444.00 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$414.00 |
| D0220 |
Intraoral - periapical first radiographic image |
20 |
18 |
$180.00 |