| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
467 |
467 |
$18K |
| D1206 |
Topical application of fluoride varnish |
538 |
538 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
389 |
389 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
105 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$1K |
| D0274 |
Bitewings - four radiographic images |
38 |
38 |
$1K |
| D0272 |
Bitewings - two radiographic images |
30 |
30 |
$650.22 |
| D0220 |
Intraoral - periapical first radiographic image |
32 |
32 |
$544.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
24 |
$234.00 |