| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,549 |
6,362 |
$177K |
| D0120 |
Periodic oral evaluation - established patient |
9,802 |
9,468 |
$177K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,038 |
1,360 |
$165K |
| D1208 |
Topical application of fluoride, excluding varnish |
11,385 |
10,951 |
$161K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,629 |
1,020 |
$108K |
| D1110 |
Prophylaxis - adult |
2,358 |
2,284 |
$84K |
| D0330 |
Panoramic radiographic image |
1,553 |
1,497 |
$73K |
| D1999 |
|
2,936 |
2,751 |
$53K |
| D0272 |
Bitewings - two radiographic images |
2,691 |
2,629 |
$47K |
| D1351 |
Sealant - per tooth |
1,250 |
404 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,265 |
1,211 |
$29K |
| D0145 |
Oral evaluation for a patient under three years of age |
305 |
296 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
186 |
173 |
$5K |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$396.00 |