| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
792 |
788 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
395 |
393 |
$10K |
| D1206 |
Topical application of fluoride varnish |
593 |
590 |
$9K |
| D1351 |
Sealant - per tooth |
424 |
124 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
375 |
374 |
$6K |
| D0272 |
Bitewings - two radiographic images |
562 |
560 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
220 |
220 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
371 |
346 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
363 |
361 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
16 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$240.00 |