| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,378 |
2,015 |
$46K |
| D1351 |
Sealant - per tooth |
1,937 |
222 |
$38K |
| D1206 |
Topical application of fluoride varnish |
1,961 |
1,691 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,071 |
902 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
993 |
848 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
233 |
210 |
$13K |
| D0274 |
Bitewings - four radiographic images |
751 |
649 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
69 |
$8K |
| D0330 |
Panoramic radiographic image |
464 |
399 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
357 |
227 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
69 |
26 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
14 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
195 |
140 |
$1K |
| D0272 |
Bitewings - two radiographic images |
111 |
83 |
$994.70 |
| D1208 |
Topical application of fluoride, excluding varnish |
98 |
73 |
$856.90 |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$278.32 |
| D1330 |
|
191 |
142 |
$0.00 |
| D1999 |
|
75 |
74 |
$0.00 |