| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
546 |
524 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
304 |
110 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
490 |
475 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
243 |
233 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
148 |
72 |
$9K |
| D0274 |
Bitewings - four radiographic images |
344 |
325 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,662 |
648 |
$6K |
| D1351 |
Sealant - per tooth |
207 |
48 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
88 |
81 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
405 |
384 |
$3K |
| D1110 |
Prophylaxis - adult |
79 |
73 |
$3K |
| D1206 |
Topical application of fluoride varnish |
224 |
219 |
$2K |
| D9430 |
|
65 |
64 |
$2K |
| D0272 |
Bitewings - two radiographic images |
114 |
113 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
112 |
107 |
$1K |
| D0350 |
|
309 |
126 |
$1K |
| D0330 |
Panoramic radiographic image |
29 |
27 |
$600.00 |