| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
220 |
220 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
310 |
307 |
$9K |
| D1351 |
Sealant - per tooth |
126 |
51 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
141 |
141 |
$4K |
| D0274 |
Bitewings - four radiographic images |
149 |
148 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
81 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
311 |
289 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
219 |
188 |
$1K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
15 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$265.48 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$248.56 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$121.99 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$80.21 |