| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
143 |
143 |
$4K |
| D1206 |
Topical application of fluoride varnish |
145 |
145 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
14 |
$2K |
| D0272 |
Bitewings - two radiographic images |
98 |
98 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
49 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
56 |
56 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
99 |
99 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
90 |
90 |
$772.12 |