| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,511 |
1,282 |
$64K |
| D1206 |
Topical application of fluoride varnish |
1,758 |
1,501 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
1,393 |
1,193 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
312 |
205 |
$23K |
| D1351 |
Sealant - per tooth |
1,148 |
328 |
$23K |
| D0274 |
Bitewings - four radiographic images |
556 |
474 |
$13K |
| D0330 |
Panoramic radiographic image |
235 |
188 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
198 |
120 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
332 |
254 |
$10K |
| D0272 |
Bitewings - two radiographic images |
492 |
451 |
$9K |
| D1110 |
Prophylaxis - adult |
168 |
149 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
275 |
207 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
32 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
54 |
$2K |
| D9310 |
|
54 |
49 |
$1K |
| D7111 |
|
24 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
121 |
76 |
$1K |