| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,291 |
2,128 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
2,011 |
1,860 |
$52K |
| D1206 |
Topical application of fluoride varnish |
1,931 |
1,776 |
$46K |
| D1351 |
Sealant - per tooth |
228 |
124 |
$15K |
| D0274 |
Bitewings - four radiographic images |
518 |
472 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
150 |
132 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
151 |
130 |
$5K |
| D0272 |
Bitewings - two radiographic images |
280 |
255 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
77 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
115 |
102 |
$593.60 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$262.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
31 |
30 |
$117.80 |