| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
639 |
626 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
769 |
361 |
$50K |
| D1120 |
Prophylaxis - child |
1,070 |
1,057 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
548 |
548 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,825 |
1,098 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
293 |
136 |
$16K |
| D1206 |
Topical application of fluoride varnish |
495 |
492 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
71 |
35 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
291 |
290 |
$3K |
| D0272 |
Bitewings - two radiographic images |
283 |
278 |
$3K |
| D1310 |
|
51 |
51 |
$2K |
| D0274 |
Bitewings - four radiographic images |
86 |
86 |
$2K |
| D1351 |
Sealant - per tooth |
39 |
12 |
$1K |
| D0350 |
|
24 |
12 |
$240.00 |