| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
355 |
355 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
388 |
388 |
$14K |
| D1351 |
Sealant - per tooth |
459 |
141 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
134 |
85 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
159 |
98 |
$11K |
| D1206 |
Topical application of fluoride varnish |
416 |
416 |
$10K |
| D1110 |
Prophylaxis - adult |
97 |
97 |
$6K |
| D0272 |
Bitewings - two radiographic images |
213 |
213 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
485 |
260 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
280 |
279 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
125 |
125 |
$4K |
| D0274 |
Bitewings - four radiographic images |
42 |
42 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$746.40 |