| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
570 |
560 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
500 |
488 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
788 |
631 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
78 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
12 |
$996.10 |
| D0220 |
Intraoral - periapical first radiographic image |
693 |
675 |
$776.41 |
| D1208 |
Topical application of fluoride, excluding varnish |
607 |
589 |
$347.36 |
| D1330 |
|
600 |
585 |
$188.42 |
| D0274 |
Bitewings - four radiographic images |
319 |
312 |
$156.00 |
| D1351 |
Sealant - per tooth |
246 |
64 |
$115.92 |
| D1110 |
Prophylaxis - adult |
28 |
27 |
$36.00 |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$16.35 |
| D0272 |
Bitewings - two radiographic images |
65 |
64 |
$0.00 |