| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
312 |
312 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
351 |
344 |
$9K |
| D1206 |
Topical application of fluoride varnish |
333 |
333 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
32 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
72 |
$3K |
| D0274 |
Bitewings - four radiographic images |
70 |
68 |
$2K |
| D1351 |
Sealant - per tooth |
81 |
26 |
$2K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$2K |
| D0272 |
Bitewings - two radiographic images |
54 |
54 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
22 |
22 |
$343.96 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
20 |
$164.14 |