| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,481 |
2,471 |
$64K |
| D1110 |
Prophylaxis - adult |
1,445 |
1,439 |
$56K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
644 |
363 |
$51K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
397 |
245 |
$40K |
| D1120 |
Prophylaxis - child |
1,321 |
1,319 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,390 |
1,386 |
$23K |
| D0274 |
Bitewings - four radiographic images |
665 |
661 |
$22K |
| D1206 |
Topical application of fluoride varnish |
981 |
980 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
232 |
231 |
$10K |
| D1351 |
Sealant - per tooth |
253 |
56 |
$7K |
| D0272 |
Bitewings - two radiographic images |
245 |
245 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
109 |
106 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
43 |
$1K |