| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
640 |
638 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
343 |
341 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
192 |
125 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
424 |
421 |
$10K |
| D1206 |
Topical application of fluoride varnish |
681 |
677 |
$9K |
| D0272 |
Bitewings - two radiographic images |
601 |
597 |
$9K |
| D1351 |
Sealant - per tooth |
393 |
115 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
140 |
87 |
$7K |
| D1110 |
Prophylaxis - adult |
33 |
31 |
$841.00 |
| D0274 |
Bitewings - four radiographic images |
37 |
35 |
$709.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$130.00 |