| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,804 |
3,670 |
$164K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,759 |
3,635 |
$102K |
| D0120 |
Periodic oral evaluation - established patient |
3,192 |
3,082 |
$98K |
| D0274 |
Bitewings - four radiographic images |
1,677 |
1,621 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
830 |
812 |
$49K |
| D0220 |
Intraoral - periapical first radiographic image |
1,860 |
1,771 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,756 |
1,636 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
54 |
$7K |
| D1351 |
Sealant - per tooth |
193 |
59 |
$7K |
| D1110 |
Prophylaxis - adult |
125 |
117 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
58 |
54 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
13 |
$2K |
| D1999 |
|
364 |
354 |
$0.00 |