| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
433 |
427 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
540 |
527 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
435 |
429 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
112 |
67 |
$6K |
| D1110 |
Prophylaxis - adult |
143 |
136 |
$6K |
| D1351 |
Sealant - per tooth |
99 |
47 |
$5K |
| D0274 |
Bitewings - four radiographic images |
200 |
195 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
103 |
94 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
80 |
76 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
40 |
32 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
134 |
121 |
$694.40 |
| D0272 |
Bitewings - two radiographic images |
68 |
64 |
$592.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
26 |
$159.60 |