| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,416 |
1,380 |
$57K |
| D0120 |
Periodic oral evaluation - established patient |
1,119 |
1,081 |
$29K |
| D1351 |
Sealant - per tooth |
523 |
206 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
769 |
741 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
606 |
564 |
$13K |
| D0274 |
Bitewings - four radiographic images |
471 |
450 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
65 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,196 |
1,147 |
$7K |
| D1206 |
Topical application of fluoride varnish |
260 |
253 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
198 |
177 |
$5K |
| D1110 |
Prophylaxis - adult |
151 |
136 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
973 |
930 |
$4K |
| D2751 |
Crown - porcelain fused to predominantly base metal |
16 |
12 |
$4K |
| D0272 |
Bitewings - two radiographic images |
215 |
208 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
94 |
92 |
$1K |