| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
688 |
680 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
739 |
727 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
621 |
617 |
$16K |
| D0274 |
Bitewings - four radiographic images |
515 |
504 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
86 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
305 |
300 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,061 |
1,039 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,084 |
970 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
89 |
57 |
$5K |
| D1351 |
Sealant - per tooth |
81 |
45 |
$4K |
| D2160 |
|
40 |
25 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
46 |
$3K |
| D0272 |
Bitewings - two radiographic images |
145 |
144 |
$1K |
| D1206 |
Topical application of fluoride varnish |
38 |
38 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
31 |
30 |
$405.00 |
| D0270 |
|
12 |
12 |
$67.20 |