| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
673 |
569 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,180 |
998 |
$26K |
| D0274 |
Bitewings - four radiographic images |
881 |
727 |
$22K |
| D1120 |
Prophylaxis - child |
595 |
512 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,514 |
1,256 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,536 |
1,089 |
$13K |
| D1206 |
Topical application of fluoride varnish |
973 |
831 |
$11K |
| D1351 |
Sealant - per tooth |
430 |
62 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
253 |
224 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
24 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
17 |
$3K |
| D0272 |
Bitewings - two radiographic images |
133 |
123 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
26 |
$706.40 |
| D0602 |
|
275 |
251 |
$33.01 |
| D1999 |
|
39 |
31 |
$20.00 |
| D0603 |
|
286 |
265 |
$0.01 |
| D0601 |
|
84 |
80 |
$0.00 |