| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,736 |
3,596 |
$77K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,502 |
4,330 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
3,189 |
3,077 |
$58K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
971 |
560 |
$47K |
| D0210 |
Intraoral - complete series of radiographic images |
543 |
523 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
558 |
355 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
839 |
802 |
$21K |
| D1110 |
Prophylaxis - adult |
452 |
444 |
$15K |
| D0272 |
Bitewings - two radiographic images |
1,108 |
1,077 |
$11K |
| D1206 |
Topical application of fluoride varnish |
259 |
255 |
$8K |
| D1351 |
Sealant - per tooth |
364 |
133 |
$7K |
| D0274 |
Bitewings - four radiographic images |
138 |
136 |
$3K |
| D2140 |
|
16 |
12 |
$640.00 |
| D0220 |
Intraoral - periapical first radiographic image |
123 |
120 |
$610.00 |