| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,107 |
1,065 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
1,299 |
1,253 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
567 |
444 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
437 |
419 |
$11K |
| D0274 |
Bitewings - four radiographic images |
501 |
485 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
147 |
123 |
$6K |
| D1351 |
Sealant - per tooth |
14 |
13 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
257 |
235 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
103 |
95 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
51 |
$1K |
| D1110 |
Prophylaxis - adult |
34 |
34 |
$879.20 |
| D0272 |
Bitewings - two radiographic images |
45 |
43 |
$423.00 |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
14 |
$421.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
33 |
$171.00 |