| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,039 |
3,030 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
2,660 |
2,557 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,322 |
1,257 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,569 |
3,545 |
$8K |
| D1110 |
Prophylaxis - adult |
902 |
890 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
2,163 |
2,147 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
347 |
345 |
$3K |
| D0274 |
Bitewings - four radiographic images |
1,107 |
1,107 |
$3K |
| D0272 |
Bitewings - two radiographic images |
767 |
755 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,657 |
1,656 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
1,412 |
1,412 |
$2K |
| D1351 |
Sealant - per tooth |
112 |
50 |
$930.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
37 |
$327.81 |
| D1354 |
|
44 |
13 |
$315.00 |
| D0240 |
|
52 |
51 |
$153.82 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
23 |
$133.50 |