| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,111 |
3,097 |
$99K |
| D0120 |
Periodic oral evaluation - established patient |
4,190 |
4,168 |
$89K |
| D1206 |
Topical application of fluoride varnish |
3,451 |
3,429 |
$63K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
811 |
387 |
$58K |
| D0274 |
Bitewings - four radiographic images |
1,620 |
1,613 |
$47K |
| D1110 |
Prophylaxis - adult |
1,028 |
1,021 |
$39K |
| D1351 |
Sealant - per tooth |
1,031 |
211 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
271 |
189 |
$16K |
| D1330 |
|
1,166 |
1,163 |
$15K |
| D1310 |
|
1,166 |
1,163 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
746 |
744 |
$14K |
| D0330 |
Panoramic radiographic image |
210 |
210 |
$8K |
| D0272 |
Bitewings - two radiographic images |
264 |
263 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
398 |
391 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
97 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
27 |
25 |
$281.55 |
| D0270 |
|
12 |
12 |
$107.52 |