| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
612 |
612 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
206 |
205 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
688 |
688 |
$4K |
| D0603 |
|
355 |
355 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
76 |
53 |
$3K |
| D0274 |
Bitewings - four radiographic images |
308 |
308 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
84 |
84 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
383 |
383 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
334 |
334 |
$1K |
| D0602 |
|
85 |
85 |
$850.00 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$495.00 |
| D1351 |
Sealant - per tooth |
41 |
14 |
$410.00 |