| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,917 |
1,787 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
2,054 |
1,910 |
$57K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,862 |
1,733 |
$47K |
| D1351 |
Sealant - per tooth |
408 |
216 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
336 |
243 |
$26K |
| D0274 |
Bitewings - four radiographic images |
938 |
853 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
115 |
81 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
447 |
390 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,742 |
1,586 |
$9K |
| D1110 |
Prophylaxis - adult |
163 |
136 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,569 |
1,424 |
$6K |
| D0272 |
Bitewings - two radiographic images |
444 |
405 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
257 |
245 |
$4K |
| D0330 |
Panoramic radiographic image |
159 |
141 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
29 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$86.80 |
| D1330 |
|
94 |
74 |
$0.00 |