| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,569 |
6,434 |
$274K |
| D1206 |
Topical application of fluoride varnish |
6,845 |
6,706 |
$236K |
| D1351 |
Sealant - per tooth |
4,139 |
1,260 |
$83K |
| D1110 |
Prophylaxis - adult |
1,607 |
1,560 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,900 |
1,768 |
$38K |
| D0274 |
Bitewings - four radiographic images |
1,146 |
1,107 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
287 |
208 |
$22K |
| T1015 |
Clinic visit/encounter, all-inclusive |
214 |
199 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
269 |
247 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
83 |
70 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
104 |
100 |
$3K |
| D0272 |
Bitewings - two radiographic images |
80 |
80 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
102 |
98 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$660.00 |