| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
105 |
105 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
127 |
126 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
102 |
102 |
$3K |
| D1351 |
Sealant - per tooth |
20 |
14 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
17 |
$1K |
| D0274 |
Bitewings - four radiographic images |
71 |
70 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
95 |
95 |
$627.95 |
| D0230 |
Intraoral - periapical each additional radiographic image |
90 |
90 |
$461.45 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$312.96 |