| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,982 |
1,941 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
2,432 |
2,387 |
$49K |
| D1110 |
Prophylaxis - adult |
830 |
811 |
$39K |
| D1206 |
Topical application of fluoride varnish |
1,858 |
1,821 |
$38K |
| D0272 |
Bitewings - two radiographic images |
672 |
656 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
542 |
528 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
288 |
274 |
$9K |
| D0274 |
Bitewings - four radiographic images |
304 |
289 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
106 |
97 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
29 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
38 |
$5K |
| D1351 |
Sealant - per tooth |
106 |
30 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$645.58 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$134.16 |