| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
581 |
565 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
453 |
418 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
143 |
58 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
90 |
44 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
539 |
534 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
397 |
392 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
548 |
507 |
$5K |
| D0274 |
Bitewings - four radiographic images |
218 |
208 |
$5K |
| D1120 |
Prophylaxis - child |
143 |
143 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
449 |
331 |
$4K |
| D1351 |
Sealant - per tooth |
58 |
13 |
$1K |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$377.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$261.95 |