| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,677 |
1,655 |
$73K |
| D1206 |
Topical application of fluoride varnish |
2,924 |
2,892 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
2,127 |
2,104 |
$64K |
| D1110 |
Prophylaxis - adult |
899 |
892 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
513 |
499 |
$27K |
| D1351 |
Sealant - per tooth |
691 |
150 |
$23K |
| D0274 |
Bitewings - four radiographic images |
659 |
651 |
$15K |
| D1330 |
|
834 |
823 |
$5K |
| D0330 |
Panoramic radiographic image |
113 |
113 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
434 |
414 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
131 |
130 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
255 |
247 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
48 |
48 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$661.64 |