| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
160 |
159 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
58 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
150 |
148 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
124 |
123 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
28 |
$1K |
| D1351 |
Sealant - per tooth |
20 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
46 |
46 |
$968.30 |
| D0220 |
Intraoral - periapical first radiographic image |
170 |
168 |
$933.40 |
| D0274 |
Bitewings - four radiographic images |
56 |
56 |
$929.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
139 |
137 |
$657.40 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$194.40 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$159.80 |