| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,824 |
1,469 |
$39K |
| D1120 |
Prophylaxis - child |
1,273 |
1,064 |
$29K |
| D1206 |
Topical application of fluoride varnish |
2,032 |
1,644 |
$26K |
| D1110 |
Prophylaxis - adult |
607 |
505 |
$19K |
| D0272 |
Bitewings - two radiographic images |
519 |
428 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
26 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
16 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
109 |
105 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
26 |
$1K |
| D1351 |
Sealant - per tooth |
60 |
12 |
$777.14 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$771.65 |
| D1330 |
|
214 |
164 |
$0.00 |