| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
844 |
838 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
690 |
685 |
$14K |
| D1206 |
Topical application of fluoride varnish |
1,004 |
999 |
$11K |
| D1351 |
Sealant - per tooth |
666 |
209 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
318 |
316 |
$9K |
| D0274 |
Bitewings - four radiographic images |
354 |
354 |
$6K |
| D0272 |
Bitewings - two radiographic images |
495 |
488 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
107 |
55 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
600 |
351 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
369 |
366 |
$3K |
| D1110 |
Prophylaxis - adult |
118 |
118 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
15 |
$796.00 |