| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
325 |
325 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
411 |
411 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
330 |
330 |
$9K |
| D1110 |
Prophylaxis - adult |
158 |
158 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
334 |
334 |
$6K |
| D0274 |
Bitewings - four radiographic images |
114 |
114 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
15 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
70 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
322 |
310 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
14 |
$2K |
| D1351 |
Sealant - per tooth |
42 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$725.00 |