| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,553 |
3,532 |
$196K |
| D1110 |
Prophylaxis - adult |
1,401 |
1,396 |
$101K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
829 |
431 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
388 |
386 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
5,415 |
5,388 |
$17K |
| D0330 |
Panoramic radiographic image |
170 |
170 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,658 |
5,635 |
$3K |
| D0272 |
Bitewings - two radiographic images |
3,244 |
3,235 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
151 |
68 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
1,117 |
1,113 |
$992.75 |
| D1351 |
Sealant - per tooth |
382 |
59 |
$840.56 |
| D0220 |
Intraoral - periapical first radiographic image |
240 |
232 |
$227.25 |
| D0230 |
Intraoral - periapical each additional radiographic image |
29 |
25 |
$0.00 |
| D1999 |
|
12 |
12 |
$0.00 |