| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
525 |
514 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
646 |
632 |
$20K |
| D1351 |
Sealant - per tooth |
196 |
114 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
230 |
161 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
160 |
120 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
235 |
167 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
399 |
399 |
$11K |
| D0274 |
Bitewings - four radiographic images |
325 |
325 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
719 |
714 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
89 |
65 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
666 |
665 |
$3K |
| D1206 |
Topical application of fluoride varnish |
77 |
71 |
$3K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$1K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$696.43 |
| D0602 |
|
50 |
46 |
$411.57 |
| D0270 |
|
56 |
55 |
$313.60 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$277.25 |
| D0601 |
|
12 |
12 |
$8.25 |