| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,012 |
2,863 |
$123K |
| D0120 |
Periodic oral evaluation - established patient |
4,270 |
4,078 |
$118K |
| D1351 |
Sealant - per tooth |
1,138 |
625 |
$90K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,718 |
2,593 |
$71K |
| D4341 |
|
330 |
162 |
$69K |
| D0274 |
Bitewings - four radiographic images |
2,591 |
2,474 |
$46K |
| D1110 |
Prophylaxis - adult |
1,049 |
1,010 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
455 |
324 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,050 |
986 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
3,624 |
3,431 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,097 |
2,945 |
$13K |
| D9110 |
|
193 |
188 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
245 |
171 |
$11K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
30 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
111 |
110 |
$2K |
| D1206 |
Topical application of fluoride varnish |
55 |
40 |
$1K |
| D4910 |
|
14 |
14 |
$938.00 |
| D0272 |
Bitewings - two radiographic images |
66 |
58 |
$592.20 |