| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,276 |
2,110 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
2,454 |
2,311 |
$75K |
| D1206 |
Topical application of fluoride varnish |
2,305 |
2,130 |
$65K |
| D5110 |
|
93 |
93 |
$34K |
| D1110 |
Prophylaxis - adult |
569 |
518 |
$27K |
| D5120 |
|
73 |
73 |
$27K |
| D1351 |
Sealant - per tooth |
503 |
187 |
$19K |
| D0274 |
Bitewings - four radiographic images |
792 |
750 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
190 |
135 |
$11K |
| D9110 |
|
119 |
115 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,435 |
1,331 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
448 |
389 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
167 |
108 |
$7K |
| D0330 |
Panoramic radiographic image |
211 |
201 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,110 |
1,032 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
155 |
154 |
$3K |
| D0272 |
Bitewings - two radiographic images |
133 |
132 |
$2K |
| D1354 |
|
64 |
34 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
13 |
$870.75 |
| D0602 |
|
288 |
251 |
$0.00 |
| D0603 |
|
76 |
67 |
$0.00 |
| D0601 |
|
693 |
628 |
$0.00 |