| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
188 |
188 |
$7K |
| D1206 |
Topical application of fluoride varnish |
210 |
210 |
$7K |
| D1351 |
Sealant - per tooth |
158 |
44 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
156 |
156 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
30 |
$3K |
| D0330 |
Panoramic radiographic image |
55 |
55 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
30 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
60 |
60 |
$2K |
| D0274 |
Bitewings - four radiographic images |
69 |
69 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
66 |
66 |
$758.00 |
| D0272 |
Bitewings - two radiographic images |
34 |
34 |
$600.00 |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$540.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
45 |
$356.00 |