| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,214 |
10,092 |
$443K |
| D0120 |
Periodic oral evaluation - established patient |
11,318 |
11,206 |
$336K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,802 |
12,676 |
$295K |
| D1351 |
Sealant - per tooth |
8,026 |
1,124 |
$274K |
| D1110 |
Prophylaxis - adult |
2,720 |
2,682 |
$163K |
| D0274 |
Bitewings - four radiographic images |
5,953 |
5,894 |
$134K |
| D0330 |
Panoramic radiographic image |
2,430 |
2,406 |
$104K |
| D0272 |
Bitewings - two radiographic images |
4,794 |
4,745 |
$73K |
| D1330 |
|
7,248 |
7,143 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
322 |
189 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
774 |
772 |
$40K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
362 |
213 |
$37K |
| D0145 |
Oral evaluation for a patient under three years of age |
333 |
332 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
37 |
$2K |
| D1206 |
Topical application of fluoride varnish |
44 |
44 |
$1K |
| D0240 |
|
56 |
55 |
$522.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$108.00 |