| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
811 |
809 |
$14K |
| D1351 |
Sealant - per tooth |
751 |
277 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
199 |
131 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
548 |
548 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
231 |
138 |
$11K |
| D1206 |
Topical application of fluoride varnish |
867 |
866 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
301 |
301 |
$9K |
| D0274 |
Bitewings - four radiographic images |
400 |
400 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
567 |
364 |
$5K |
| D0272 |
Bitewings - two radiographic images |
281 |
281 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
416 |
415 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
17 |
17 |
$91.00 |