| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
223 |
223 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
148 |
132 |
$7K |
| D1110 |
Prophylaxis - adult |
121 |
121 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
256 |
256 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
138 |
138 |
$5K |
| D0274 |
Bitewings - four radiographic images |
118 |
118 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
43 |
$3K |
| D1351 |
Sealant - per tooth |
23 |
13 |
$444.36 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$225.96 |
| D0272 |
Bitewings - two radiographic images |
177 |
177 |
$95.16 |
| D1206 |
Topical application of fluoride varnish |
257 |
257 |
$25.27 |
| D1330 |
|
355 |
355 |
$8.92 |
| D0230 |
Intraoral - periapical each additional radiographic image |
150 |
147 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
174 |
174 |
$0.00 |