| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
905 |
835 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,004 |
928 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
793 |
739 |
$20K |
| D1110 |
Prophylaxis - adult |
392 |
367 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
555 |
517 |
$11K |
| D0274 |
Bitewings - four radiographic images |
705 |
663 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,633 |
1,257 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,460 |
1,342 |
$8K |
| D1351 |
Sealant - per tooth |
42 |
25 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
28 |
$3K |
| D0270 |
|
222 |
199 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
21 |
15 |
$1K |
| D1206 |
Topical application of fluoride varnish |
41 |
35 |
$988.00 |
| D0272 |
Bitewings - two radiographic images |
48 |
44 |
$432.40 |
| D0999 |
Unspecified diagnostic procedure, by report |
22 |
12 |
$0.00 |