| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,853 |
1,753 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
1,698 |
1,619 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
764 |
713 |
$19K |
| D0274 |
Bitewings - four radiographic images |
276 |
255 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
39 |
$3K |
| D1110 |
Prophylaxis - adult |
125 |
124 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
150 |
146 |
$3K |
| D1351 |
Sealant - per tooth |
24 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
66 |
66 |
$2K |
| D0272 |
Bitewings - two radiographic images |
57 |
54 |
$535.80 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$428.90 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$243.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$226.00 |