| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,222 |
1,212 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
509 |
278 |
$34K |
| D1351 |
Sealant - per tooth |
1,143 |
365 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
919 |
916 |
$19K |
| D7111 |
|
262 |
184 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
313 |
307 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
316 |
310 |
$11K |
| D0274 |
Bitewings - four radiographic images |
488 |
486 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
89 |
73 |
$7K |
| D1206 |
Topical application of fluoride varnish |
1,156 |
1,144 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
106 |
72 |
$6K |
| D9430 |
|
187 |
183 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
47 |
38 |
$5K |
| D0272 |
Bitewings - two radiographic images |
446 |
443 |
$4K |
| D3240 |
|
47 |
38 |
$4K |
| D1510 |
|
41 |
31 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
44 |
29 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
128 |
127 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
128 |
124 |
$384.00 |