| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,651 |
1,651 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
726 |
338 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,628 |
1,628 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,472 |
1,472 |
$38K |
| D0272 |
Bitewings - two radiographic images |
1,014 |
1,014 |
$15K |
| D1351 |
Sealant - per tooth |
209 |
77 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
330 |
330 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
113 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
257 |
256 |
$3K |
| D1110 |
Prophylaxis - adult |
35 |
35 |
$2K |
| D0240 |
|
60 |
60 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$950.95 |
| D0230 |
Intraoral - periapical each additional radiographic image |
25 |
25 |
$299.39 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$290.29 |