| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
353 |
348 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
455 |
450 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
328 |
322 |
$8K |
| D0330 |
Panoramic radiographic image |
91 |
87 |
$5K |
| D1354 |
|
90 |
18 |
$5K |
| D0272 |
Bitewings - two radiographic images |
168 |
167 |
$4K |
| D1351 |
Sealant - per tooth |
108 |
19 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
108 |
106 |
$3K |
| D1110 |
Prophylaxis - adult |
69 |
67 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
16 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
65 |
64 |
$2K |
| D1206 |
Topical application of fluoride varnish |
57 |
56 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
24 |
$264.00 |