| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,607 |
4,503 |
$125K |
| D0120 |
Periodic oral evaluation - established patient |
3,718 |
3,647 |
$96K |
| D1351 |
Sealant - per tooth |
2,825 |
654 |
$78K |
| D1206 |
Topical application of fluoride varnish |
2,783 |
2,718 |
$46K |
| D0272 |
Bitewings - two radiographic images |
1,984 |
1,940 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,649 |
1,617 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,192 |
1,156 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
314 |
297 |
$13K |
| D0330 |
Panoramic radiographic image |
143 |
138 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
600 |
515 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
15 |
$3K |
| D0240 |
|
50 |
25 |
$835.50 |
| D1999 |
|
37 |
36 |
$0.00 |