| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
295 |
295 |
$12K |
| D1351 |
Sealant - per tooth |
74 |
57 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
334 |
334 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
292 |
292 |
$8K |
| D0274 |
Bitewings - four radiographic images |
339 |
338 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
46 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
529 |
523 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
481 |
452 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
90 |
$2K |
| D1110 |
Prophylaxis - adult |
37 |
37 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
27 |
$1K |
| D0272 |
Bitewings - two radiographic images |
37 |
37 |
$354.88 |