| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
567 |
521 |
$22K |
| D1351 |
Sealant - per tooth |
678 |
151 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
269 |
138 |
$13K |
| D0274 |
Bitewings - four radiographic images |
615 |
559 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
219 |
192 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
387 |
356 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,111 |
668 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
247 |
139 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
286 |
260 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
678 |
613 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
365 |
321 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
454 |
422 |
$4K |
| D1110 |
Prophylaxis - adult |
62 |
62 |
$1K |
| D0350 |
|
14 |
14 |
$287.00 |
| D4355 |
|
24 |
14 |
$140.00 |