| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,579 |
3,476 |
$153K |
| D1206 |
Topical application of fluoride varnish |
3,505 |
3,401 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
2,508 |
2,436 |
$81K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
974 |
956 |
$60K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
534 |
289 |
$55K |
| D0274 |
Bitewings - four radiographic images |
845 |
829 |
$38K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
247 |
133 |
$27K |
| D0272 |
Bitewings - two radiographic images |
332 |
321 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
459 |
444 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
61 |
40 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
153 |
149 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
53 |
52 |
$5K |
| D1351 |
Sealant - per tooth |
128 |
32 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
42 |
41 |
$1K |