| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,195 |
1,190 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,209 |
1,204 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
1,091 |
1,073 |
$31K |
| D1351 |
Sealant - per tooth |
324 |
196 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
1,280 |
1,254 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
91 |
70 |
$8K |
| D0274 |
Bitewings - four radiographic images |
456 |
452 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,307 |
1,205 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
88 |
88 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
52 |
49 |
$2K |
| D0272 |
Bitewings - two radiographic images |
98 |
95 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
34 |
32 |
$1K |