| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
349 |
349 |
$20K |
| D1206 |
Topical application of fluoride varnish |
361 |
361 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
299 |
299 |
$10K |
| D1351 |
Sealant - per tooth |
260 |
61 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
30 |
$3K |
| D0272 |
Bitewings - two radiographic images |
260 |
260 |
$3K |
| D0240 |
|
215 |
215 |
$3K |
| D0603 |
|
220 |
220 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
51 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
128 |
127 |
$894.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
18 |
$120.00 |