| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,841 |
1,841 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
1,644 |
1,644 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
415 |
268 |
$41K |
| D1206 |
Topical application of fluoride varnish |
919 |
919 |
$27K |
| D0272 |
Bitewings - two radiographic images |
1,114 |
1,114 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,111 |
1,111 |
$15K |
| D1351 |
Sealant - per tooth |
239 |
89 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
283 |
283 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
314 |
312 |
$4K |
| D0240 |
|
100 |
100 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
12 |
12 |
$600.60 |
| D9990 |
|
43 |
32 |
$473.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
43 |
$315.14 |