| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,375 |
1,361 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,548 |
1,548 |
$41K |
| D1206 |
Topical application of fluoride varnish |
1,644 |
1,643 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
264 |
163 |
$31K |
| D1110 |
Prophylaxis - adult |
517 |
516 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
158 |
108 |
$14K |
| D0272 |
Bitewings - two radiographic images |
464 |
464 |
$11K |
| D1351 |
Sealant - per tooth |
274 |
95 |
$7K |
| D0274 |
Bitewings - four radiographic images |
167 |
166 |
$5K |
| D0330 |
Panoramic radiographic image |
66 |
66 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
57 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
75 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
42 |
41 |
$668.67 |