| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
197 |
197 |
$8K |
| D1351 |
Sealant - per tooth |
221 |
55 |
$6K |
| D1206 |
Topical application of fluoride varnish |
218 |
216 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
150 |
150 |
$4K |
| D0272 |
Bitewings - two radiographic images |
147 |
145 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
211 |
207 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
232 |
198 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
16 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$733.80 |