| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
954 |
951 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
535 |
321 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,501 |
1,500 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,456 |
1,453 |
$26K |
| D1351 |
Sealant - per tooth |
1,045 |
262 |
$26K |
| D1110 |
Prophylaxis - adult |
609 |
609 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
273 |
182 |
$15K |
| D0274 |
Bitewings - four radiographic images |
450 |
450 |
$13K |
| D0272 |
Bitewings - two radiographic images |
485 |
484 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
313 |
311 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
84 |
56 |
$6K |
| D0330 |
Panoramic radiographic image |
75 |
75 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
193 |
193 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
35 |
35 |
$657.36 |
| D9110 |
|
12 |
12 |
$415.50 |