| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
731 |
698 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
737 |
712 |
$20K |
| D1351 |
Sealant - per tooth |
185 |
79 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
312 |
299 |
$8K |
| D1206 |
Topical application of fluoride varnish |
313 |
295 |
$8K |
| D0274 |
Bitewings - four radiographic images |
397 |
376 |
$6K |
| D1110 |
Prophylaxis - adult |
160 |
156 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
92 |
58 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
927 |
880 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
950 |
831 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
172 |
164 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
170 |
158 |
$2K |
| D0272 |
Bitewings - two radiographic images |
144 |
138 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
40 |
$664.20 |