| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
653 |
652 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
181 |
92 |
$23K |
| D1351 |
Sealant - per tooth |
660 |
231 |
$19K |
| D1206 |
Topical application of fluoride varnish |
678 |
677 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
321 |
321 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
107 |
67 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
342 |
341 |
$9K |
| D0274 |
Bitewings - four radiographic images |
196 |
196 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
219 |
219 |
$4K |
| D0272 |
Bitewings - two radiographic images |
132 |
132 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
219 |
205 |
$2K |
| D1110 |
Prophylaxis - adult |
30 |
30 |
$2K |