| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,294 |
1,294 |
$42K |
| D1351 |
Sealant - per tooth |
1,285 |
285 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,021 |
1,020 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,323 |
1,322 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
249 |
115 |
$13K |
| D1110 |
Prophylaxis - adult |
309 |
309 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
563 |
563 |
$13K |
| D0240 |
|
622 |
571 |
$12K |
| D0272 |
Bitewings - two radiographic images |
853 |
852 |
$11K |
| D1206 |
Topical application of fluoride varnish |
343 |
342 |
$7K |
| D0330 |
Panoramic radiographic image |
136 |
136 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
264 |
263 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
81 |
81 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
200 |
200 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
41 |
$519.27 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$149.11 |