| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
305 |
304 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
377 |
373 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
138 |
124 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
290 |
289 |
$8K |
| D0274 |
Bitewings - four radiographic images |
241 |
241 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
37 |
31 |
$4K |
| D0330 |
Panoramic radiographic image |
125 |
124 |
$3K |
| D1351 |
Sealant - per tooth |
36 |
30 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
118 |
118 |
$3K |
| D1110 |
Prophylaxis - adult |
40 |
40 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
133 |
133 |
$879.13 |
| D0230 |
Intraoral - periapical each additional radiographic image |
98 |
98 |
$828.80 |
| D0272 |
Bitewings - two radiographic images |
74 |
74 |
$809.57 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
12 |
12 |
$436.80 |