| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,466 |
1,461 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
1,553 |
1,546 |
$56K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
755 |
472 |
$56K |
| D1206 |
Topical application of fluoride varnish |
1,762 |
1,754 |
$55K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
131 |
103 |
$11K |
| D1110 |
Prophylaxis - adult |
180 |
180 |
$7K |
| D1351 |
Sealant - per tooth |
204 |
44 |
$4K |
| D0274 |
Bitewings - four radiographic images |
96 |
96 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
94 |
$3K |
| D0602 |
|
320 |
320 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
192 |
189 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
155 |
145 |
$2K |
| D0603 |
|
173 |
173 |
$2K |
| D0350 |
|
214 |
214 |
$1K |
| D0240 |
|
50 |
50 |
$980.00 |
| D0272 |
Bitewings - two radiographic images |
90 |
90 |
$900.00 |