| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,148 |
1,104 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,085 |
1,035 |
$28K |
| D1351 |
Sealant - per tooth |
642 |
225 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,012 |
974 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
963 |
920 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
390 |
373 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
196 |
110 |
$11K |
| D0274 |
Bitewings - four radiographic images |
485 |
461 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,278 |
1,185 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
142 |
75 |
$6K |
| D1110 |
Prophylaxis - adult |
153 |
136 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
59 |
30 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
862 |
809 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
206 |
197 |
$3K |
| D0272 |
Bitewings - two radiographic images |
76 |
73 |
$695.60 |