| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,042 |
1,041 |
$45K |
| D1351 |
Sealant - per tooth |
309 |
217 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,048 |
1,048 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
818 |
817 |
$22K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
154 |
102 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
133 |
100 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
409 |
408 |
$11K |
| D0274 |
Bitewings - four radiographic images |
538 |
534 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,042 |
1,031 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
336 |
331 |
$6K |
| D1110 |
Prophylaxis - adult |
100 |
100 |
$5K |
| D4341 |
|
21 |
12 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
62 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
822 |
811 |
$4K |
| D0330 |
Panoramic radiographic image |
167 |
166 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
134 |
134 |
$4K |
| D1206 |
Topical application of fluoride varnish |
55 |
55 |
$2K |
| D0272 |
Bitewings - two radiographic images |
137 |
137 |
$1K |