| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,443 |
4,271 |
$189K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,274 |
4,113 |
$115K |
| D0274 |
Bitewings - four radiographic images |
2,190 |
2,115 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
2,652 |
2,574 |
$87K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
594 |
421 |
$62K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
663 |
454 |
$56K |
| D0330 |
Panoramic radiographic image |
648 |
627 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
163 |
158 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
380 |
254 |
$7K |
| D9940 |
|
13 |
13 |
$4K |
| D1351 |
Sealant - per tooth |
85 |
28 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$611.52 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
24 |
$366.52 |