| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
711 |
704 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
555 |
553 |
$13K |
| D1206 |
Topical application of fluoride varnish |
755 |
749 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
233 |
233 |
$7K |
| D0274 |
Bitewings - four radiographic images |
273 |
271 |
$5K |
| D0272 |
Bitewings - two radiographic images |
357 |
356 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
376 |
249 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
32 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
264 |
263 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
27 |
$2K |
| D1351 |
Sealant - per tooth |
84 |
25 |
$1K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$1K |