| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
762 |
759 |
$30K |
| D1351 |
Sealant - per tooth |
624 |
289 |
$25K |
| D1206 |
Topical application of fluoride varnish |
760 |
758 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
667 |
665 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
168 |
78 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
161 |
75 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
138 |
101 |
$831.70 |
| D0220 |
Intraoral - periapical first radiographic image |
120 |
109 |
$644.00 |
| D0272 |
Bitewings - two radiographic images |
65 |
60 |
$592.20 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$492.00 |
| D0274 |
Bitewings - four radiographic images |
22 |
22 |
$371.80 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$127.80 |
| D0602 |
|
253 |
252 |
$0.00 |
| D0601 |
|
406 |
406 |
$0.00 |