| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
150 |
145 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
220 |
211 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
59 |
30 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
145 |
139 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
76 |
72 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
61 |
58 |
$2K |
| D0274 |
Bitewings - four radiographic images |
87 |
80 |
$1K |
| D2950 |
|
18 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
194 |
179 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
203 |
190 |
$1K |
| D1351 |
Sealant - per tooth |
31 |
14 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$770.40 |
| D9110 |
|
15 |
13 |
$715.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$122.20 |