| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,049 |
1,049 |
$40K |
| D1206 |
Topical application of fluoride varnish |
1,371 |
1,371 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
259 |
126 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
701 |
701 |
$18K |
| D0272 |
Bitewings - two radiographic images |
180 |
180 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$2K |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$1K |
| D1351 |
Sealant - per tooth |
27 |
12 |
$511.12 |