| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,647 |
5,216 |
$218K |
| D1206 |
Topical application of fluoride varnish |
4,688 |
4,314 |
$114K |
| D0120 |
Periodic oral evaluation - established patient |
4,191 |
3,853 |
$110K |
| D1351 |
Sealant - per tooth |
1,064 |
589 |
$75K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
982 |
959 |
$24K |
| D0274 |
Bitewings - four radiographic images |
1,325 |
1,259 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
169 |
136 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
147 |
127 |
$7K |
| D0330 |
Panoramic radiographic image |
237 |
226 |
$5K |
| D0272 |
Bitewings - two radiographic images |
389 |
381 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
80 |
75 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
91 |
90 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
168 |
148 |
$821.18 |
| D0230 |
Intraoral - periapical each additional radiographic image |
34 |
29 |
$106.40 |