| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
212 |
204 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
191 |
184 |
$4K |
| D1351 |
Sealant - per tooth |
96 |
17 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
129 |
123 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
116 |
111 |
$1K |
| D0240 |
|
66 |
61 |
$596.97 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$484.50 |
| D0220 |
Intraoral - periapical first radiographic image |
59 |
55 |
$443.52 |
| D9920 |
|
15 |
12 |
$365.30 |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
14 |
$33.18 |