| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
518 |
488 |
$25K |
| D1120 |
Prophylaxis - child |
380 |
361 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
534 |
508 |
$16K |
| D4341 |
|
153 |
64 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
533 |
503 |
$12K |
| D1206 |
Topical application of fluoride varnish |
707 |
675 |
$10K |
| D0330 |
Panoramic radiographic image |
249 |
242 |
$10K |
| D0274 |
Bitewings - four radiographic images |
317 |
300 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
135 |
130 |
$8K |
| D1351 |
Sealant - per tooth |
421 |
86 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
51 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
581 |
546 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
662 |
446 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
17 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$574.20 |
| D0272 |
Bitewings - two radiographic images |
24 |
19 |
$279.72 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
14 |
$171.45 |