| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
261 |
261 |
$11K |
| D1206 |
Topical application of fluoride varnish |
216 |
216 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
353 |
353 |
$6K |
| D1351 |
Sealant - per tooth |
149 |
24 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
80 |
80 |
$2K |
| D0272 |
Bitewings - two radiographic images |
55 |
55 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$490.00 |