| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,806 |
6,706 |
$176K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,507 |
1,008 |
$156K |
| D1110 |
Prophylaxis - adult |
2,927 |
2,876 |
$109K |
| D1206 |
Topical application of fluoride varnish |
5,673 |
5,594 |
$92K |
| D1120 |
Prophylaxis - child |
3,301 |
3,253 |
$89K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
832 |
619 |
$65K |
| D0274 |
Bitewings - four radiographic images |
788 |
773 |
$25K |
| D0272 |
Bitewings - two radiographic images |
719 |
713 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
27 |
$4K |
| D1351 |
Sealant - per tooth |
106 |
39 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
69 |
$2K |
| D0330 |
Panoramic radiographic image |
37 |
37 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
53 |
52 |
$734.36 |