| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
302 |
299 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
107 |
82 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
125 |
125 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
62 |
62 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
73 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
92 |
92 |
$5K |
| D1110 |
Prophylaxis - adult |
42 |
42 |
$5K |
| D1351 |
Sealant - per tooth |
499 |
161 |
$5K |
| D1206 |
Topical application of fluoride varnish |
436 |
432 |
$3K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
113 |
112 |
$1K |
| D0191 |
|
311 |
308 |
$634.74 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$116.55 |
| D1330 |
|
429 |
425 |
$16.06 |
| D3120 |
|
20 |
15 |
$0.00 |