| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
876 |
875 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
922 |
921 |
$25K |
| D1351 |
Sealant - per tooth |
434 |
125 |
$16K |
| D1206 |
Topical application of fluoride varnish |
461 |
461 |
$12K |
| D0272 |
Bitewings - two radiographic images |
624 |
624 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
594 |
594 |
$8K |
| D0274 |
Bitewings - four radiographic images |
237 |
237 |
$6K |
| D1110 |
Prophylaxis - adult |
114 |
114 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
86 |
46 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
406 |
406 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
57 |
34 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
193 |
193 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
350 |
350 |
$3K |
| D2160 |
|
32 |
21 |
$3K |
| D9990 |
|
15 |
15 |
$275.00 |