| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
536 |
503 |
$24K |
| D1206 |
Topical application of fluoride varnish |
563 |
525 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
730 |
702 |
$22K |
| D0274 |
Bitewings - four radiographic images |
683 |
648 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,006 |
950 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,734 |
848 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
483 |
458 |
$9K |
| D0330 |
Panoramic radiographic image |
201 |
192 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
231 |
212 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
140 |
55 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
52 |
50 |
$3K |
| D1351 |
Sealant - per tooth |
195 |
26 |
$2K |
| D4346 |
|
20 |
15 |
$689.00 |
| D0270 |
|
13 |
13 |
$141.48 |