| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,635 |
2,632 |
$109K |
| D0120 |
Periodic oral evaluation - established patient |
2,761 |
2,761 |
$77K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,567 |
2,567 |
$35K |
| D0272 |
Bitewings - two radiographic images |
1,532 |
1,532 |
$24K |
| D1110 |
Prophylaxis - adult |
343 |
343 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
212 |
144 |
$18K |
| D1206 |
Topical application of fluoride varnish |
522 |
522 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
622 |
616 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
223 |
223 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
526 |
525 |
$4K |
| D0274 |
Bitewings - four radiographic images |
138 |
138 |
$3K |
| D1351 |
Sealant - per tooth |
86 |
28 |
$3K |
| D0240 |
|
120 |
120 |
$2K |
| D9990 |
|
114 |
109 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$480.00 |