| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
3,600 |
3,526 |
$186K |
| D1120 |
Prophylaxis - child |
3,068 |
3,001 |
$169K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,839 |
1,810 |
$58K |
| D0120 |
Periodic oral evaluation - established patient |
1,535 |
1,510 |
$49K |
| D0350 |
|
4,529 |
1,697 |
$46K |
| D1351 |
Sealant - per tooth |
1,680 |
347 |
$36K |
| D0272 |
Bitewings - two radiographic images |
1,554 |
1,521 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
2,769 |
2,704 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,071 |
1,045 |
$24K |
| D1110 |
Prophylaxis - adult |
397 |
395 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,987 |
2,601 |
$17K |
| D0240 |
|
406 |
304 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
87 |
78 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
13 |
$1K |
| D1353 |
|
33 |
12 |
$524.80 |