| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,769 |
3,681 |
$159K |
| D1206 |
Topical application of fluoride varnish |
4,728 |
4,622 |
$115K |
| D0120 |
Periodic oral evaluation - established patient |
3,556 |
3,476 |
$102K |
| D1110 |
Prophylaxis - adult |
714 |
707 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
548 |
542 |
$29K |
| D1351 |
Sealant - per tooth |
695 |
189 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,581 |
1,537 |
$23K |
| D0330 |
Panoramic radiographic image |
452 |
450 |
$20K |
| D1330 |
|
2,901 |
2,831 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
142 |
106 |
$14K |
| D0274 |
Bitewings - four radiographic images |
308 |
307 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
61 |
43 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
299 |
294 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
99 |
97 |
$848.16 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$520.00 |