| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,300 |
4,087 |
$172K |
| D1351 |
Sealant - per tooth |
2,004 |
1,004 |
$149K |
| D0120 |
Periodic oral evaluation - established patient |
4,164 |
3,981 |
$114K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,779 |
3,598 |
$96K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
710 |
531 |
$53K |
| D0274 |
Bitewings - four radiographic images |
1,892 |
1,781 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
3,555 |
3,333 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,387 |
3,157 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
468 |
438 |
$10K |
| D1110 |
Prophylaxis - adult |
158 |
148 |
$5K |
| D0272 |
Bitewings - two radiographic images |
456 |
422 |
$4K |
| D1206 |
Topical application of fluoride varnish |
108 |
108 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
187 |
177 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
72 |
64 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
15 |
$1K |
| D0270 |
|
68 |
68 |
$380.80 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$248.60 |