| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,043 |
1,042 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
541 |
541 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
316 |
188 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
752 |
748 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,186 |
1,150 |
$18K |
| D1206 |
Topical application of fluoride varnish |
1,079 |
1,078 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
217 |
149 |
$15K |
| D0272 |
Bitewings - two radiographic images |
678 |
677 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
866 |
813 |
$9K |
| D0274 |
Bitewings - four radiographic images |
212 |
212 |
$8K |
| D1351 |
Sealant - per tooth |
181 |
57 |
$6K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$2K |
| D1354 |
|
51 |
25 |
$294.60 |