| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,281 |
1,245 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,327 |
1,283 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
514 |
397 |
$29K |
| D1351 |
Sealant - per tooth |
466 |
233 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
746 |
731 |
$18K |
| D1110 |
Prophylaxis - adult |
375 |
348 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
172 |
139 |
$11K |
| D0274 |
Bitewings - four radiographic images |
584 |
558 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,701 |
1,622 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
450 |
427 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,540 |
1,475 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
53 |
$2K |
| D0272 |
Bitewings - two radiographic images |
221 |
219 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
105 |
99 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
32 |
26 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$703.70 |