| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
145 |
145 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
217 |
215 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
39 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
121 |
121 |
$3K |
| D0330 |
Panoramic radiographic image |
130 |
128 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
112 |
111 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
74 |
74 |
$1K |
| D1351 |
Sealant - per tooth |
15 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$618.80 |
| D0272 |
Bitewings - two radiographic images |
48 |
48 |
$468.21 |
| D0274 |
Bitewings - four radiographic images |
17 |
17 |
$326.56 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
14 |
$85.93 |