| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,250 |
1,210 |
$44K |
| D0120 |
Periodic oral evaluation - established patient |
2,445 |
2,343 |
$44K |
| D1120 |
Prophylaxis - child |
1,264 |
1,203 |
$34K |
| D1206 |
Topical application of fluoride varnish |
1,549 |
1,500 |
$30K |
| D1999 |
|
874 |
767 |
$17K |
| D0274 |
Bitewings - four radiographic images |
668 |
655 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,487 |
714 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
914 |
867 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
975 |
902 |
$10K |
| D0330 |
Panoramic radiographic image |
137 |
136 |
$7K |
| D0272 |
Bitewings - two radiographic images |
339 |
334 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D1351 |
Sealant - per tooth |
32 |
12 |
$728.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
12 |
$360.80 |