| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
138 |
137 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
27 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
140 |
139 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
84 |
84 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$908.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
49 |
14 |
$686.00 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
28 |
$557.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$330.00 |