| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
488 |
465 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
221 |
164 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
428 |
408 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
409 |
386 |
$10K |
| D1351 |
Sealant - per tooth |
232 |
88 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
168 |
164 |
$3K |
| D0274 |
Bitewings - four radiographic images |
176 |
170 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
418 |
402 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
50 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
363 |
342 |
$1K |
| D0272 |
Bitewings - two radiographic images |
108 |
102 |
$911.80 |
| D0140 |
Limited oral evaluation - problem focused |
70 |
66 |
$858.60 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$254.00 |