| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,177 |
1,162 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,204 |
1,183 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,078 |
1,065 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,699 |
1,463 |
$12K |
| D0274 |
Bitewings - four radiographic images |
667 |
651 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,676 |
1,624 |
$10K |
| D1351 |
Sealant - per tooth |
113 |
57 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
119 |
97 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
290 |
280 |
$6K |
| D1110 |
Prophylaxis - adult |
89 |
82 |
$3K |
| D9110 |
|
58 |
58 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
57 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
28 |
26 |
$2K |
| D1206 |
Topical application of fluoride varnish |
39 |
39 |
$1K |
| D0272 |
Bitewings - two radiographic images |
91 |
90 |
$931.45 |
| D0140 |
Limited oral evaluation - problem focused |
46 |
38 |
$712.80 |
| D0270 |
|
118 |
111 |
$669.65 |