| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
565 |
565 |
$25K |
| D1206 |
Topical application of fluoride varnish |
582 |
581 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
652 |
651 |
$16K |
| D1351 |
Sealant - per tooth |
414 |
110 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
61 |
38 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
603 |
600 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
624 |
621 |
$3K |
| D1110 |
Prophylaxis - adult |
69 |
69 |
$3K |
| D0272 |
Bitewings - two radiographic images |
298 |
298 |
$3K |
| D0274 |
Bitewings - four radiographic images |
237 |
236 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
45 |
43 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
28 |
$2K |
| D0602 |
|
71 |
71 |
$710.00 |
| D0603 |
|
27 |
27 |
$270.00 |