| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1354 |
|
1,425 |
99 |
$108K |
| D1110 |
Prophylaxis - adult |
626 |
596 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,760 |
1,684 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
176 |
108 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
1,353 |
1,253 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
891 |
861 |
$18K |
| D0274 |
Bitewings - four radiographic images |
541 |
503 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
486 |
449 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,736 |
1,006 |
$13K |
| D1120 |
Prophylaxis - child |
449 |
449 |
$13K |
| D0330 |
Panoramic radiographic image |
219 |
206 |
$11K |
| D1351 |
Sealant - per tooth |
286 |
70 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
97 |
61 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
77 |
76 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$159.61 |