| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,892 |
4,329 |
$133K |
| D0120 |
Periodic oral evaluation - established patient |
3,671 |
3,529 |
$102K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
853 |
580 |
$92K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,782 |
4,245 |
$74K |
| D0330 |
Panoramic radiographic image |
1,497 |
1,244 |
$61K |
| D0274 |
Bitewings - four radiographic images |
1,301 |
1,068 |
$31K |
| D0140 |
Limited oral evaluation - problem focused |
1,182 |
794 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
354 |
236 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,175 |
745 |
$24K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
57 |
40 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
140 |
42 |
$2K |
| D1351 |
Sealant - per tooth |
384 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
61 |
55 |
$871.36 |