| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
580 |
569 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
593 |
581 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
335 |
335 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
239 |
225 |
$10K |
| D0272 |
Bitewings - two radiographic images |
262 |
258 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
17 |
$3K |
| D1351 |
Sealant - per tooth |
48 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$108.13 |