| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,725 |
2,628 |
$123K |
| D1110 |
Prophylaxis - adult |
2,266 |
2,191 |
$105K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,374 |
4,200 |
$103K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,730 |
4,550 |
$66K |
| D0274 |
Bitewings - four radiographic images |
1,513 |
1,457 |
$43K |
| D0330 |
Panoramic radiographic image |
500 |
477 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
489 |
482 |
$13K |
| D0272 |
Bitewings - two radiographic images |
661 |
624 |
$10K |
| D1351 |
Sealant - per tooth |
558 |
118 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
44 |
$3K |
| D2140 |
|
56 |
25 |
$2K |
| D9110 |
|
50 |
41 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$845.00 |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
56 |
$492.56 |