| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,111 |
1,109 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,154 |
1,151 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,026 |
1,025 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
150 |
67 |
$18K |
| D0274 |
Bitewings - four radiographic images |
505 |
505 |
$13K |
| D1110 |
Prophylaxis - adult |
259 |
258 |
$13K |
| D1351 |
Sealant - per tooth |
405 |
58 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
750 |
745 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
266 |
265 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
689 |
649 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
14 |
$4K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$1K |
| D0240 |
|
40 |
20 |
$736.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$729.00 |