| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,576 |
1,565 |
$78K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
996 |
514 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
1,026 |
1,015 |
$63K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
344 |
342 |
$22K |
| D0274 |
Bitewings - four radiographic images |
838 |
830 |
$17K |
| D1206 |
Topical application of fluoride varnish |
898 |
897 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,945 |
1,490 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
131 |
84 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
623 |
612 |
$9K |
| D0272 |
Bitewings - two radiographic images |
476 |
471 |
$6K |
| D1320 |
|
568 |
566 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
32 |
$3K |
| D0350 |
|
83 |
26 |
$691.20 |