| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
818 |
818 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
940 |
939 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
731 |
731 |
$20K |
| D1110 |
Prophylaxis - adult |
234 |
233 |
$11K |
| D0274 |
Bitewings - four radiographic images |
545 |
543 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
135 |
109 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
426 |
425 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
141 |
125 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,088 |
1,071 |
$7K |
| D4341 |
|
19 |
13 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
155 |
155 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
274 |
267 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
886 |
880 |
$4K |
| D1351 |
Sealant - per tooth |
37 |
27 |
$4K |
| D0272 |
Bitewings - two radiographic images |
142 |
141 |
$2K |
| D0270 |
|
210 |
209 |
$1K |