| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
794 |
782 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,416 |
1,402 |
$40K |
| D1120 |
Prophylaxis - child |
910 |
898 |
$32K |
| D1351 |
Sealant - per tooth |
1,076 |
171 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,035 |
1,022 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,532 |
1,060 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,865 |
1,840 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,394 |
1,313 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
104 |
41 |
$10K |
| D0145 |
Oral evaluation for a patient under three years of age |
69 |
69 |
$10K |
| D0330 |
Panoramic radiographic image |
296 |
285 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
164 |
162 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$290.06 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$176.40 |
| D0601 |
|
913 |
910 |
$0.00 |
| D0603 |
|
959 |
947 |
$0.00 |
| D0602 |
|
12 |
12 |
$0.00 |