| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
251 |
250 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
251 |
250 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
144 |
144 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$3K |
| D1351 |
Sealant - per tooth |
21 |
14 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
60 |
60 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
240 |
240 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
230 |
230 |
$1K |
| D0274 |
Bitewings - four radiographic images |
46 |
46 |
$917.24 |