| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
912 |
912 |
$20K |
| D1110 |
Prophylaxis - adult |
405 |
405 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
150 |
124 |
$14K |
| D0274 |
Bitewings - four radiographic images |
625 |
625 |
$14K |
| D1120 |
Prophylaxis - child |
351 |
351 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
338 |
338 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
321 |
317 |
$3K |
| D1351 |
Sealant - per tooth |
13 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
13 |
$617.10 |
| D0230 |
Intraoral - periapical each additional radiographic image |
81 |
81 |
$497.56 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$314.16 |