| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
726 |
716 |
$17K |
| D1120 |
Prophylaxis - child |
485 |
475 |
$10K |
| D0272 |
Bitewings - two radiographic images |
426 |
417 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
507 |
496 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
37 |
$4K |
| D1110 |
Prophylaxis - adult |
157 |
157 |
$4K |
| D1206 |
Topical application of fluoride varnish |
353 |
353 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
53 |
53 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$1K |
| D1351 |
Sealant - per tooth |
49 |
13 |
$931.00 |