| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
155 |
155 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
131 |
131 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
13 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
117 |
116 |
$2K |
| D1120 |
Prophylaxis - child |
42 |
42 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
49 |
49 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
105 |
63 |
$991.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$555.14 |