| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,636 |
2,711 |
$79K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,409 |
2,096 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
768 |
286 |
$54K |
| D0330 |
Panoramic radiographic image |
1,665 |
1,313 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,142 |
2,832 |
$46K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
379 |
160 |
$38K |
| D0140 |
Limited oral evaluation - problem focused |
1,099 |
938 |
$36K |
| D0274 |
Bitewings - four radiographic images |
2,112 |
1,416 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,189 |
1,061 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,590 |
1,412 |
$16K |
| D1351 |
Sealant - per tooth |
312 |
28 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
608 |
541 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
292 |
84 |
$6K |
| D0272 |
Bitewings - two radiographic images |
408 |
281 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
25 |
$5K |
| D1110 |
Prophylaxis - adult |
297 |
134 |
$4K |
| D1206 |
Topical application of fluoride varnish |
153 |
98 |
$2K |