| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,145 |
5,095 |
$150K |
| D1206 |
Topical application of fluoride varnish |
6,315 |
6,260 |
$114K |
| D0120 |
Periodic oral evaluation - established patient |
5,640 |
5,586 |
$97K |
| D1110 |
Prophylaxis - adult |
1,057 |
1,052 |
$42K |
| D0272 |
Bitewings - two radiographic images |
1,401 |
1,383 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
205 |
126 |
$17K |
| D0330 |
Panoramic radiographic image |
217 |
216 |
$10K |
| D1351 |
Sealant - per tooth |
280 |
76 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
114 |
49 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
275 |
275 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
110 |
110 |
$4K |
| D0274 |
Bitewings - four radiographic images |
111 |
111 |
$2K |
| D9630 |
|
90 |
90 |
$1K |