| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,161 |
1,160 |
$32K |
| D0274 |
Bitewings - four radiographic images |
886 |
885 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
991 |
991 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
566 |
565 |
$19K |
| D1206 |
Topical application of fluoride varnish |
938 |
938 |
$15K |
| D1110 |
Prophylaxis - adult |
288 |
288 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
123 |
79 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
478 |
477 |
$8K |
| D0272 |
Bitewings - two radiographic images |
263 |
263 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
374 |
369 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
43 |
$3K |
| D1351 |
Sealant - per tooth |
130 |
40 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
24 |
$251.63 |