| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
701 |
701 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
900 |
899 |
$26K |
| D1351 |
Sealant - per tooth |
134 |
98 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
482 |
482 |
$13K |
| D1110 |
Prophylaxis - adult |
221 |
221 |
$11K |
| D0274 |
Bitewings - four radiographic images |
489 |
489 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
129 |
113 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,039 |
1,026 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
257 |
257 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
240 |
234 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
96 |
88 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
889 |
886 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
91 |
91 |
$2K |
| D0330 |
Panoramic radiographic image |
66 |
66 |
$2K |
| D1206 |
Topical application of fluoride varnish |
48 |
48 |
$1K |
| D0270 |
|
122 |
121 |
$683.20 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$310.52 |