| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
449 |
414 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
223 |
168 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
502 |
451 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
433 |
399 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
402 |
375 |
$8K |
| D0274 |
Bitewings - four radiographic images |
470 |
441 |
$6K |
| D1351 |
Sealant - per tooth |
61 |
35 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
162 |
155 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
761 |
675 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
703 |
610 |
$4K |
| D1110 |
Prophylaxis - adult |
59 |
59 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
27 |
23 |
$253.80 |