| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,856 |
2,847 |
$127K |
| D0120 |
Periodic oral evaluation - established patient |
2,917 |
2,902 |
$70K |
| D1206 |
Topical application of fluoride varnish |
3,496 |
3,483 |
$65K |
| D1120 |
Prophylaxis - child |
1,836 |
1,830 |
$59K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
2,517 |
2,447 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,004 |
996 |
$30K |
| 90472 |
Immunization administration, each additional vaccine (list separately) |
1,124 |
1,097 |
$24K |
| D1351 |
Sealant - per tooth |
514 |
151 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
36 |
$8K |
| D0272 |
Bitewings - two radiographic images |
203 |
203 |
$4K |
| 90658 |
|
504 |
495 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$2K |
| 90651 |
|
63 |
62 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
24 |
22 |
$755.01 |
| 90686 |
|
141 |
139 |
$736.77 |
| 90715 |
|
165 |
164 |
$551.01 |
| 90734 |
|
66 |
66 |
$307.82 |
| 90633 |
|
138 |
137 |
$119.40 |
| 90696 |
|
27 |
27 |
$0.00 |
| 90647 |
|
32 |
30 |
$0.00 |
| 90619 |
|
16 |
16 |
$0.00 |
| 90723 |
|
34 |
31 |
$0.00 |
| 90670 |
|
81 |
78 |
$0.00 |
| 90710 |
|
28 |
28 |
$0.00 |