| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
230 |
230 |
$27K |
| D0274 |
Bitewings - four radiographic images |
163 |
163 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$2K |
| D1120 |
Prophylaxis - child |
213 |
213 |
$2K |
| D1206 |
Topical application of fluoride varnish |
335 |
335 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
16 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
14 |
$1K |
| D9248 |
|
13 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
32 |
32 |
$144.01 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$55.92 |