| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
123 |
123 |
$5K |
| D1351 |
Sealant - per tooth |
132 |
45 |
$4K |
| D1206 |
Topical application of fluoride varnish |
126 |
126 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
15 |
$3K |
| D0274 |
Bitewings - four radiographic images |
61 |
61 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
50 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
66 |
66 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
33 |
33 |
$544.00 |
| D0272 |
Bitewings - two radiographic images |
20 |
20 |
$500.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
37 |
32 |
$324.00 |