| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,877 |
4,851 |
$235K |
| D1206 |
Topical application of fluoride varnish |
7,131 |
7,087 |
$163K |
| D1354 |
|
6,151 |
1,375 |
$161K |
| D0190 |
|
7,251 |
7,192 |
$144K |
| D1351 |
Sealant - per tooth |
3,243 |
626 |
$98K |
| D1110 |
Prophylaxis - adult |
1,238 |
1,234 |
$79K |
| D2940 |
|
1,257 |
309 |
$74K |
| D4341 |
|
294 |
98 |
$37K |
| D0274 |
Bitewings - four radiographic images |
801 |
796 |
$34K |
| D0140 |
Limited oral evaluation - problem focused |
579 |
577 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
905 |
902 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
431 |
428 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
461 |
460 |
$29K |
| D0272 |
Bitewings - two radiographic images |
610 |
609 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
973 |
970 |
$19K |
| D4910 |
|
148 |
146 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
933 |
739 |
$13K |
| D0330 |
Panoramic radiographic image |
203 |
203 |
$13K |
| D5110 |
|
12 |
12 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
28 |
$5K |
| D1330 |
|
123 |
122 |
$3K |
| D9920 |
|
23 |
22 |
$1K |
| D1310 |
|
34 |
34 |
$877.14 |
| D0270 |
|
14 |
14 |
$265.92 |
| D0602 |
|
1,027 |
1,021 |
$0.00 |
| D0603 |
|
2,222 |
2,202 |
$0.00 |
| D0601 |
|
257 |
256 |
$0.00 |
| D0350 |
|
2,432 |
2,403 |
$0.00 |
| D9996 |
|
1,355 |
1,351 |
$0.00 |