| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,268 |
1,262 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
359 |
259 |
$46K |
| D1206 |
Topical application of fluoride varnish |
1,554 |
1,544 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,391 |
1,386 |
$38K |
| D1110 |
Prophylaxis - adult |
726 |
724 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
610 |
603 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
329 |
326 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
240 |
159 |
$24K |
| D1351 |
Sealant - per tooth |
725 |
130 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
534 |
524 |
$9K |
| D0274 |
Bitewings - four radiographic images |
269 |
268 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
296 |
285 |
$3K |
| D0272 |
Bitewings - two radiographic images |
110 |
110 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
28 |
$1K |