| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
589 |
589 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
770 |
768 |
$21K |
| D1110 |
Prophylaxis - adult |
378 |
377 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
763 |
762 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
133 |
96 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
151 |
150 |
$11K |
| D1351 |
Sealant - per tooth |
304 |
84 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
431 |
424 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
71 |
55 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
147 |
146 |
$6K |
| D0274 |
Bitewings - four radiographic images |
149 |
149 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
383 |
367 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$3K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$300.00 |