| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
219 |
208 |
$8K |
| D1206 |
Topical application of fluoride varnish |
218 |
207 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
180 |
167 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
31 |
$2K |
| D0274 |
Bitewings - four radiographic images |
76 |
73 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
55 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
91 |
85 |
$453.60 |
| D0272 |
Bitewings - two radiographic images |
32 |
32 |
$272.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
36 |
$184.40 |