| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,871 |
1,866 |
$59K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,684 |
2,672 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,930 |
1,925 |
$45K |
| D1110 |
Prophylaxis - adult |
941 |
936 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
857 |
850 |
$24K |
| D0330 |
Panoramic radiographic image |
322 |
318 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
238 |
236 |
$14K |
| D1351 |
Sealant - per tooth |
108 |
28 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
52 |
52 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
51 |
$1K |
| D0272 |
Bitewings - two radiographic images |
53 |
53 |
$880.32 |