| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
383 |
383 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
458 |
458 |
$13K |
| D1351 |
Sealant - per tooth |
197 |
82 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
368 |
368 |
$10K |
| D1110 |
Prophylaxis - adult |
122 |
122 |
$6K |
| D0274 |
Bitewings - four radiographic images |
270 |
270 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
57 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
133 |
133 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
393 |
392 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
419 |
365 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
25 |
$2K |
| D0272 |
Bitewings - two radiographic images |
61 |
61 |
$643.22 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$535.36 |