| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
761 |
756 |
$28K |
| D1120 |
Prophylaxis - child |
747 |
737 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
248 |
165 |
$16K |
| D0274 |
Bitewings - four radiographic images |
571 |
560 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,652 |
983 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
131 |
83 |
$7K |
| D1206 |
Topical application of fluoride varnish |
607 |
598 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$3K |
| D0350 |
|
202 |
119 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
69 |
60 |
$828.00 |
| D1351 |
Sealant - per tooth |
34 |
12 |
$748.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
45 |
45 |
$390.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$168.00 |