| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,712 |
1,676 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,771 |
1,728 |
$28K |
| D1110 |
Prophylaxis - adult |
644 |
630 |
$23K |
| D1120 |
Prophylaxis - child |
618 |
604 |
$13K |
| D0274 |
Bitewings - four radiographic images |
421 |
414 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
611 |
596 |
$5K |
| D1351 |
Sealant - per tooth |
187 |
56 |
$3K |
| D1999 |
|
195 |
171 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
510 |
498 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$468.90 |
| D0272 |
Bitewings - two radiographic images |
13 |
12 |
$123.48 |