| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
153 |
153 |
$10K |
| D1206 |
Topical application of fluoride varnish |
127 |
127 |
$5K |
| D1120 |
Prophylaxis - child |
74 |
74 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
32 |
32 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
13 |
$3K |
| D0330 |
Panoramic radiographic image |
20 |
20 |
$2K |
| D0274 |
Bitewings - four radiographic images |
34 |
34 |
$2K |
| D1351 |
Sealant - per tooth |
45 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
20 |
20 |
$860.00 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
27 |
$726.00 |