| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
86 |
86 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
88 |
88 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
77 |
77 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
28 |
$2K |
| D1351 |
Sealant - per tooth |
46 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
59 |
$2K |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$932.28 |
| D0220 |
Intraoral - periapical first radiographic image |
144 |
140 |
$925.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
130 |
110 |
$577.92 |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$516.24 |
| D0210 |
Intraoral - complete series of radiographic images |
20 |
19 |
$422.03 |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$232.89 |