| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,120 |
4,032 |
$177K |
| D0120 |
Periodic oral evaluation - established patient |
5,436 |
5,339 |
$160K |
| D1206 |
Topical application of fluoride varnish |
6,101 |
5,977 |
$150K |
| D1351 |
Sealant - per tooth |
2,710 |
659 |
$89K |
| D1110 |
Prophylaxis - adult |
1,084 |
1,074 |
$65K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
353 |
200 |
$42K |
| D0330 |
Panoramic radiographic image |
517 |
510 |
$21K |
| D1330 |
|
2,413 |
2,361 |
$15K |
| D0274 |
Bitewings - four radiographic images |
541 |
532 |
$12K |
| D0272 |
Bitewings - two radiographic images |
482 |
475 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
62 |
41 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
62 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
37 |
36 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
79 |
$774.00 |