| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,603 |
1,557 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
2,007 |
1,950 |
$55K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,001 |
978 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
372 |
287 |
$23K |
| D0274 |
Bitewings - four radiographic images |
643 |
623 |
$11K |
| D1110 |
Prophylaxis - adult |
282 |
277 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,377 |
1,336 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
206 |
137 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,082 |
1,051 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
147 |
147 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
187 |
181 |
$3K |
| D1351 |
Sealant - per tooth |
42 |
30 |
$2K |
| D0272 |
Bitewings - two radiographic images |
43 |
43 |
$404.20 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$304.80 |
| D1999 |
|
170 |
142 |
$0.00 |