| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,718 |
1,713 |
$93K |
| D0120 |
Periodic oral evaluation - established patient |
2,080 |
2,072 |
$63K |
| D1206 |
Topical application of fluoride varnish |
1,924 |
1,919 |
$53K |
| D1110 |
Prophylaxis - adult |
654 |
652 |
$48K |
| D0274 |
Bitewings - four radiographic images |
684 |
684 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
174 |
99 |
$21K |
| D0330 |
Panoramic radiographic image |
185 |
184 |
$14K |
| D1351 |
Sealant - per tooth |
323 |
78 |
$13K |
| D0272 |
Bitewings - two radiographic images |
276 |
275 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
100 |
99 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
171 |
167 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
15 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
67 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$578.00 |