| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
475 |
454 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
505 |
480 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
384 |
368 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
331 |
317 |
$9K |
| D1351 |
Sealant - per tooth |
90 |
42 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
217 |
206 |
$5K |
| D4341 |
|
40 |
26 |
$5K |
| D0274 |
Bitewings - four radiographic images |
319 |
296 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
592 |
554 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
488 |
450 |
$2K |
| D1110 |
Prophylaxis - adult |
46 |
44 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
18 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
89 |
85 |
$1K |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$253.80 |