| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
140 |
110 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
85 |
48 |
$5K |
| D1351 |
Sealant - per tooth |
68 |
32 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
45 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
127 |
93 |
$3K |
| D9110 |
|
41 |
31 |
$2K |
| D1206 |
Topical application of fluoride varnish |
78 |
64 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
76 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
175 |
138 |
$1K |
| D0274 |
Bitewings - four radiographic images |
93 |
72 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
196 |
153 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
69 |
50 |
$937.60 |
| D1110 |
Prophylaxis - adult |
19 |
15 |
$381.00 |
| D0270 |
|
24 |
17 |
$134.40 |