| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
113 |
113 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
39 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
26 |
$5K |
| D1120 |
Prophylaxis - child |
110 |
110 |
$2K |
| D0274 |
Bitewings - four radiographic images |
131 |
131 |
$2K |
| D1206 |
Topical application of fluoride varnish |
253 |
253 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
14 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
24 |
12 |
$731.25 |
| D0220 |
Intraoral - periapical first radiographic image |
28 |
25 |
$271.60 |