| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
845 |
809 |
$33K |
| D1351 |
Sealant - per tooth |
450 |
238 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
808 |
777 |
$21K |
| D1206 |
Topical application of fluoride varnish |
820 |
784 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
245 |
172 |
$15K |
| D0274 |
Bitewings - four radiographic images |
344 |
323 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
969 |
922 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
912 |
861 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
77 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
170 |
158 |
$3K |
| D0272 |
Bitewings - two radiographic images |
366 |
352 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
24 |
$2K |
| D1110 |
Prophylaxis - adult |
58 |
55 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
41 |
$664.20 |
| D0270 |
|
65 |
64 |
$364.00 |