| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
94 |
94 |
$3K |
| D1120 |
Prophylaxis - child |
87 |
87 |
$2K |
| D1351 |
Sealant - per tooth |
66 |
21 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
22 |
$952.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
19 |
$702.00 |
| D7111 |
|
24 |
14 |
$672.00 |
| D0120 |
Periodic oral evaluation - established patient |
67 |
67 |
$670.00 |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$616.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
20 |
20 |
$400.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$360.00 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$350.00 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$150.00 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$150.00 |