| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,063 |
2,876 |
$122K |
| D1351 |
Sealant - per tooth |
1,191 |
660 |
$101K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,007 |
586 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
2,595 |
2,427 |
$70K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,592 |
2,434 |
$65K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,262 |
1,194 |
$28K |
| D0274 |
Bitewings - four radiographic images |
1,424 |
1,335 |
$26K |
| D1110 |
Prophylaxis - adult |
158 |
144 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
296 |
292 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
50 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
588 |
574 |
$4K |
| D0272 |
Bitewings - two radiographic images |
248 |
223 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$1K |
| D1206 |
Topical application of fluoride varnish |
33 |
29 |
$832.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
26 |
$198.88 |