| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
329 |
329 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
436 |
436 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
338 |
338 |
$9K |
| D1110 |
Prophylaxis - adult |
150 |
150 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
84 |
51 |
$8K |
| D0274 |
Bitewings - four radiographic images |
171 |
171 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
368 |
368 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
119 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
15 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
353 |
342 |
$3K |
| D1351 |
Sealant - per tooth |
103 |
26 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$563.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$275.00 |