| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
592 |
592 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
169 |
87 |
$21K |
| D1206 |
Topical application of fluoride varnish |
603 |
603 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
303 |
303 |
$13K |
| D1351 |
Sealant - per tooth |
376 |
133 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
106 |
65 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
296 |
296 |
$8K |
| D0274 |
Bitewings - four radiographic images |
202 |
202 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
202 |
202 |
$3K |
| D0272 |
Bitewings - two radiographic images |
141 |
141 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
209 |
183 |
$2K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$756.00 |