| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,317 |
1,311 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,006 |
1,000 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
888 |
883 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
848 |
837 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
228 |
169 |
$15K |
| D0274 |
Bitewings - four radiographic images |
652 |
647 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,235 |
1,220 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,125 |
1,089 |
$7K |
| D1110 |
Prophylaxis - adult |
133 |
131 |
$6K |
| D1206 |
Topical application of fluoride varnish |
237 |
237 |
$6K |
| D0272 |
Bitewings - two radiographic images |
262 |
261 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
136 |
134 |
$3K |
| D1351 |
Sealant - per tooth |
39 |
15 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
16 |
16 |
$463.81 |
| D0330 |
Panoramic radiographic image |
14 |
13 |
$252.00 |