| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,882 |
1,844 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
2,441 |
2,367 |
$63K |
| D0274 |
Bitewings - four radiographic images |
1,837 |
1,797 |
$51K |
| D1351 |
Sealant - per tooth |
1,409 |
259 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,511 |
2,455 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
320 |
192 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
360 |
214 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
2,252 |
2,203 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,203 |
2,151 |
$22K |
| D1120 |
Prophylaxis - child |
690 |
675 |
$22K |
| D0272 |
Bitewings - two radiographic images |
611 |
601 |
$11K |
| D0330 |
Panoramic radiographic image |
284 |
278 |
$9K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$147.00 |
| D0350 |
|
61 |
60 |
$128.66 |
| D0602 |
|
676 |
665 |
$0.00 |
| D0603 |
|
1,312 |
1,285 |
$0.00 |
| D9986 |
|
164 |
156 |
$0.00 |
| D9987 |
|
12 |
12 |
$0.00 |