| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
214 |
211 |
$7K |
| D1351 |
Sealant - per tooth |
262 |
59 |
$7K |
| D0272 |
Bitewings - two radiographic images |
219 |
216 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
28 |
28 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
139 |
134 |
$4K |
| D1206 |
Topical application of fluoride varnish |
238 |
233 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
282 |
274 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
65 |
64 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
262 |
250 |
$2K |
| D0603 |
|
455 |
448 |
$0.00 |