| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
991 |
932 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
282 |
141 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,102 |
809 |
$32K |
| D1206 |
Topical application of fluoride varnish |
1,231 |
1,170 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
809 |
770 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
415 |
393 |
$23K |
| D0274 |
Bitewings - four radiographic images |
451 |
431 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
897 |
880 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
162 |
103 |
$17K |
| D0272 |
Bitewings - two radiographic images |
447 |
433 |
$15K |
| D1110 |
Prophylaxis - adult |
204 |
198 |
$14K |
| D0330 |
Panoramic radiographic image |
170 |
159 |
$14K |
| D1351 |
Sealant - per tooth |
175 |
62 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$653.00 |