| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
688 |
686 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
773 |
772 |
$22K |
| D1351 |
Sealant - per tooth |
199 |
150 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
232 |
201 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
573 |
572 |
$15K |
| D1110 |
Prophylaxis - adult |
183 |
183 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
176 |
138 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
308 |
307 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
205 |
204 |
$7K |
| D0274 |
Bitewings - four radiographic images |
257 |
256 |
$5K |
| D4341 |
|
22 |
12 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
606 |
592 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
138 |
137 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
467 |
463 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
19 |
$2K |
| D0272 |
Bitewings - two radiographic images |
141 |
141 |
$2K |
| D4910 |
|
12 |
12 |
$804.00 |