| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,530 |
2,524 |
$103K |
| D0120 |
Periodic oral evaluation - established patient |
2,778 |
2,774 |
$78K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,067 |
2,061 |
$53K |
| D1351 |
Sealant - per tooth |
400 |
305 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
587 |
484 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,590 |
1,587 |
$30K |
| D4341 |
|
151 |
96 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,185 |
1,178 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
543 |
455 |
$28K |
| D1110 |
Prophylaxis - adult |
524 |
524 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
3,030 |
3,008 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
660 |
648 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,424 |
2,421 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
218 |
216 |
$7K |
| D0272 |
Bitewings - two radiographic images |
555 |
553 |
$6K |
| D1206 |
Topical application of fluoride varnish |
214 |
214 |
$5K |
| D4910 |
|
14 |
14 |
$938.00 |
| D1999 |
|
133 |
113 |
$0.00 |