| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,252 |
3,092 |
$128K |
| D0120 |
Periodic oral evaluation - established patient |
3,748 |
3,573 |
$100K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,048 |
1,940 |
$51K |
| D0274 |
Bitewings - four radiographic images |
1,215 |
1,140 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
2,692 |
2,535 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
247 |
199 |
$13K |
| D1110 |
Prophylaxis - adult |
331 |
312 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
292 |
250 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,338 |
2,195 |
$9K |
| D0272 |
Bitewings - two radiographic images |
630 |
586 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
251 |
233 |
$4K |
| D1351 |
Sealant - per tooth |
18 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
52 |
52 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
33 |
27 |
$744.02 |
| D0270 |
|
25 |
25 |
$123.20 |