| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,240 |
1,210 |
$12K |
| D1206 |
Topical application of fluoride varnish |
1,243 |
1,209 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
588 |
562 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,782 |
1,655 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
810 |
793 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,732 |
1,520 |
$5K |
| D0330 |
Panoramic radiographic image |
511 |
457 |
$5K |
| D0272 |
Bitewings - two radiographic images |
717 |
695 |
$4K |
| D1351 |
Sealant - per tooth |
293 |
88 |
$3K |
| D0274 |
Bitewings - four radiographic images |
388 |
370 |
$2K |
| D1110 |
Prophylaxis - adult |
146 |
139 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
26 |
$2K |
| D1354 |
|
227 |
67 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
136 |
129 |
$903.25 |
| D1208 |
Topical application of fluoride, excluding varnish |
148 |
146 |
$379.72 |
| D0340 |
|
15 |
15 |
$101.90 |
| D0191 |
|
16 |
16 |
$58.48 |
| D0270 |
|
30 |
26 |
$11.14 |