| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
619 |
619 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
890 |
890 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
243 |
141 |
$24K |
| D1110 |
Prophylaxis - adult |
328 |
328 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
712 |
708 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
240 |
240 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
129 |
67 |
$9K |
| D1206 |
Topical application of fluoride varnish |
405 |
405 |
$8K |
| D1351 |
Sealant - per tooth |
227 |
53 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
656 |
528 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
222 |
222 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
77 |
77 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
102 |
98 |
$4K |
| D0274 |
Bitewings - four radiographic images |
124 |
124 |
$4K |
| D0272 |
Bitewings - two radiographic images |
82 |
82 |
$2K |