| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
77 |
72 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
96 |
91 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
31 |
$2K |
| D1206 |
Topical application of fluoride varnish |
61 |
57 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
20 |
$1K |
| D1110 |
Prophylaxis - adult |
35 |
35 |
$1K |
| D1351 |
Sealant - per tooth |
21 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
56 |
56 |
$828.10 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$294.70 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$243.00 |
| D0220 |
Intraoral - periapical first radiographic image |
43 |
43 |
$240.80 |