| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
564 |
564 |
$16K |
| D1351 |
Sealant - per tooth |
570 |
108 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
624 |
623 |
$9K |
| D0274 |
Bitewings - four radiographic images |
228 |
228 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
588 |
587 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
75 |
47 |
$7K |
| D1110 |
Prophylaxis - adult |
127 |
127 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
544 |
544 |
$6K |
| D1120 |
Prophylaxis - child |
125 |
125 |
$5K |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$631.26 |
| D0602 |
|
627 |
626 |
$0.00 |