| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
606 |
606 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
188 |
116 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
655 |
655 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
692 |
692 |
$15K |
| D1110 |
Prophylaxis - adult |
217 |
217 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
386 |
383 |
$6K |
| D0274 |
Bitewings - four radiographic images |
177 |
177 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
130 |
130 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
492 |
318 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
47 |
47 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
26 |
$3K |
| D0272 |
Bitewings - two radiographic images |
59 |
59 |
$1K |
| D1351 |
Sealant - per tooth |
36 |
12 |
$1K |