| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,376 |
2,368 |
$98K |
| D0120 |
Periodic oral evaluation - established patient |
2,712 |
2,706 |
$76K |
| D1351 |
Sealant - per tooth |
1,070 |
539 |
$69K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,323 |
2,315 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
497 |
394 |
$35K |
| D1110 |
Prophylaxis - adult |
717 |
717 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
643 |
478 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,561 |
1,558 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
926 |
922 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,763 |
1,748 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
540 |
523 |
$10K |
| D0272 |
Bitewings - two radiographic images |
689 |
687 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,090 |
1,054 |
$7K |
| D9110 |
|
12 |
12 |
$660.00 |
| D0270 |
|
12 |
12 |
$67.20 |
| D1999 |
|
1,128 |
1,063 |
$0.00 |