| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,975 |
2,923 |
$128K |
| D1206 |
Topical application of fluoride varnish |
5,019 |
4,938 |
$124K |
| D0120 |
Periodic oral evaluation - established patient |
3,726 |
3,663 |
$110K |
| D1110 |
Prophylaxis - adult |
1,685 |
1,657 |
$104K |
| D1351 |
Sealant - per tooth |
2,639 |
478 |
$87K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
605 |
368 |
$78K |
| D0274 |
Bitewings - four radiographic images |
2,644 |
2,602 |
$60K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
299 |
180 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
791 |
786 |
$43K |
| D0330 |
Panoramic radiographic image |
779 |
771 |
$35K |
| D1330 |
|
2,395 |
2,355 |
$15K |
| D0272 |
Bitewings - two radiographic images |
689 |
683 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
191 |
187 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
413 |
389 |
$5K |
| D3120 |
|
21 |
15 |
$735.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
13 |
$118.08 |