| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,210 |
1,183 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,114 |
1,103 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
774 |
751 |
$20K |
| D4341 |
|
54 |
24 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
377 |
364 |
$7K |
| D0274 |
Bitewings - four radiographic images |
413 |
406 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,132 |
1,102 |
$7K |
| D1351 |
Sealant - per tooth |
60 |
40 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
69 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
992 |
969 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
96 |
93 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
19 |
$3K |
| D0330 |
Panoramic radiographic image |
106 |
98 |
$2K |
| D1206 |
Topical application of fluoride varnish |
93 |
93 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
57 |
56 |
$1K |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$729.80 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$546.00 |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$371.25 |
| D0270 |
|
42 |
42 |
$229.60 |