| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,463 |
2,436 |
$73K |
| D0120 |
Periodic oral evaluation - established patient |
3,119 |
3,085 |
$64K |
| D1110 |
Prophylaxis - adult |
1,442 |
1,427 |
$64K |
| D1206 |
Topical application of fluoride varnish |
3,337 |
3,283 |
$53K |
| D0330 |
Panoramic radiographic image |
941 |
941 |
$45K |
| D0274 |
Bitewings - four radiographic images |
830 |
830 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
744 |
744 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,044 |
1,044 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,141 |
1,107 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
484 |
484 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
153 |
96 |
$13K |
| D1351 |
Sealant - per tooth |
535 |
135 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
622 |
622 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
682 |
627 |
$5K |
| D0601 |
|
24 |
24 |
$201.30 |