| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
578 |
538 |
$26K |
| D1206 |
Topical application of fluoride varnish |
624 |
577 |
$26K |
| D0274 |
Bitewings - four radiographic images |
907 |
845 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
540 |
496 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
1,169 |
1,089 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
731 |
678 |
$13K |
| D5214 |
|
57 |
42 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,846 |
929 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
268 |
244 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
188 |
93 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
143 |
66 |
$5K |
| D5110 |
|
17 |
12 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
96 |
87 |
$5K |
| D1351 |
Sealant - per tooth |
187 |
29 |
$4K |
| D0330 |
Panoramic radiographic image |
84 |
74 |
$3K |
| D5213 |
|
19 |
13 |
$2K |