| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
282 |
282 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
138 |
138 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
303 |
303 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
242 |
242 |
$8K |
| D7111 |
|
99 |
60 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
24 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
35 |
$5K |
| D0272 |
Bitewings - two radiographic images |
207 |
207 |
$5K |
| D1110 |
Prophylaxis - adult |
75 |
75 |
$4K |
| D1351 |
Sealant - per tooth |
111 |
29 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
88 |
87 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18 |
13 |
$252.00 |