| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
159 |
159 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
221 |
221 |
$6K |
| D1206 |
Topical application of fluoride varnish |
169 |
169 |
$5K |
| D1110 |
Prophylaxis - adult |
77 |
77 |
$3K |
| D1351 |
Sealant - per tooth |
172 |
38 |
$3K |
| D0274 |
Bitewings - four radiographic images |
124 |
124 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
260 |
259 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
230 |
230 |
$834.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$540.00 |
| D0272 |
Bitewings - two radiographic images |
42 |
42 |
$420.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$375.00 |
| D0601 |
|
15 |
15 |
$150.00 |
| D0603 |
|
12 |
12 |
$120.00 |