| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
4,124 |
4,035 |
$102K |
| D1110 |
Prophylaxis - adult |
1,628 |
1,592 |
$98K |
| D0120 |
Periodic oral evaluation - established patient |
2,995 |
2,926 |
$88K |
| D1120 |
Prophylaxis - child |
1,642 |
1,596 |
$70K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
436 |
212 |
$54K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
282 |
106 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,673 |
1,632 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
618 |
601 |
$34K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
264 |
150 |
$25K |
| D0330 |
Panoramic radiographic image |
532 |
517 |
$24K |
| D1351 |
Sealant - per tooth |
675 |
111 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
381 |
355 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
453 |
406 |
$5K |
| D0272 |
Bitewings - two radiographic images |
136 |
136 |
$2K |
| D1330 |
|
156 |
155 |
$936.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
57 |
52 |
$505.12 |