| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,398 |
2,282 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
2,418 |
2,315 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
736 |
442 |
$60K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,744 |
1,664 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,616 |
1,528 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
994 |
929 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
2,706 |
2,422 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
152 |
100 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,369 |
2,134 |
$8K |
| D1351 |
Sealant - per tooth |
91 |
29 |
$5K |
| D1110 |
Prophylaxis - adult |
67 |
61 |
$3K |
| D9110 |
|
14 |
12 |
$676.00 |
| D0272 |
Bitewings - two radiographic images |
25 |
24 |
$216.20 |
| D1999 |
|
12 |
12 |
$0.00 |