| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
793 |
635 |
$27K |
| D1120 |
Prophylaxis - child |
530 |
418 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
483 |
397 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
159 |
91 |
$9K |
| D1110 |
Prophylaxis - adult |
259 |
231 |
$9K |
| D1351 |
Sealant - per tooth |
410 |
63 |
$8K |
| D0274 |
Bitewings - four radiographic images |
336 |
270 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
287 |
249 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
105 |
50 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
84 |
82 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
40 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
37 |
13 |
$943.50 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
13 |
$468.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$341.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$234.00 |