| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
958 |
941 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
1,239 |
1,216 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,429 |
1,402 |
$34K |
| D1110 |
Prophylaxis - adult |
389 |
380 |
$24K |
| D0274 |
Bitewings - four radiographic images |
578 |
555 |
$22K |
| D0272 |
Bitewings - two radiographic images |
537 |
534 |
$18K |
| D0330 |
Panoramic radiographic image |
191 |
190 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
136 |
$8K |
| D1351 |
Sealant - per tooth |
202 |
70 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
39 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
42 |
42 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
18 |
18 |
$292.53 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$240.97 |
| D0603 |
|
1,305 |
1,278 |
$1.47 |
| D1999 |
|
26 |
26 |
$0.03 |
| D1330 |
|
42 |
42 |
$0.00 |