| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,208 |
1,130 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,200 |
1,142 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,133 |
1,062 |
$29K |
| D9110 |
|
95 |
89 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
580 |
522 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
694 |
644 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
24 |
$2K |
| D1351 |
Sealant - per tooth |
46 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
26 |
$2K |
| D0274 |
Bitewings - four radiographic images |
71 |
66 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
17 |
$505.20 |
| D0272 |
Bitewings - two radiographic images |
13 |
12 |
$122.20 |
| D1999 |
|
12 |
12 |
$0.00 |