| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,307 |
2,299 |
$119K |
| D0120 |
Periodic oral evaluation - established patient |
1,338 |
1,335 |
$95K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,413 |
686 |
$94K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,348 |
1,336 |
$88K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
922 |
500 |
$50K |
| D0274 |
Bitewings - four radiographic images |
1,816 |
1,810 |
$38K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,970 |
2,354 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,006 |
1,995 |
$29K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
199 |
142 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
227 |
221 |
$11K |
| D1351 |
Sealant - per tooth |
201 |
51 |
$8K |
| D1206 |
Topical application of fluoride varnish |
358 |
358 |
$6K |
| D0272 |
Bitewings - two radiographic images |
253 |
252 |
$3K |
| D1110 |
Prophylaxis - adult |
23 |
20 |
$2K |
| D9430 |
|
49 |
47 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
127 |
122 |
$1K |
| D4910 |
|
17 |
15 |
$1K |