| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,483 |
1,462 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,336 |
2,312 |
$41K |
| D1110 |
Prophylaxis - adult |
880 |
877 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,643 |
1,627 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
717 |
711 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
246 |
176 |
$10K |
| D1351 |
Sealant - per tooth |
316 |
107 |
$9K |
| D0274 |
Bitewings - four radiographic images |
390 |
386 |
$8K |
| D0272 |
Bitewings - two radiographic images |
449 |
445 |
$7K |
| D0330 |
Panoramic radiographic image |
159 |
159 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
60 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
115 |
114 |
$306.66 |
| D0140 |
Limited oral evaluation - problem focused |
48 |
48 |
$0.00 |