| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
868 |
800 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
863 |
804 |
$24K |
| D1351 |
Sealant - per tooth |
323 |
174 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
324 |
215 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
529 |
481 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
206 |
153 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
426 |
399 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
312 |
299 |
$9K |
| D0274 |
Bitewings - four radiographic images |
363 |
335 |
$6K |
| D4341 |
|
33 |
12 |
$5K |
| D1110 |
Prophylaxis - adult |
112 |
110 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
784 |
709 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
40 |
31 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
623 |
569 |
$2K |
| D0272 |
Bitewings - two radiographic images |
125 |
110 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
45 |
43 |
$712.80 |