| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,179 |
2,030 |
$87K |
| D0120 |
Periodic oral evaluation - established patient |
1,586 |
1,504 |
$43K |
| D1351 |
Sealant - per tooth |
505 |
269 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,168 |
1,059 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
320 |
221 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,359 |
2,056 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
202 |
131 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
674 |
592 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
2,338 |
2,118 |
$13K |
| D0274 |
Bitewings - four radiographic images |
653 |
593 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
428 |
418 |
$11K |
| D0272 |
Bitewings - two radiographic images |
224 |
202 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
89 |
82 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$863.80 |
| D1110 |
Prophylaxis - adult |
30 |
29 |
$863.20 |
| D9110 |
|
12 |
12 |
$660.00 |