| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
643 |
582 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
572 |
509 |
$15K |
| D1206 |
Topical application of fluoride varnish |
534 |
475 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
69 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
14 |
$1K |
| D0274 |
Bitewings - four radiographic images |
73 |
66 |
$1K |
| D1351 |
Sealant - per tooth |
25 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
67 |
66 |
$629.80 |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
24 |
$624.00 |
| D0220 |
Intraoral - periapical first radiographic image |
34 |
25 |
$134.40 |