| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,666 |
2,624 |
$166K |
| D1206 |
Topical application of fluoride varnish |
5,119 |
5,049 |
$128K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
937 |
403 |
$117K |
| D0120 |
Periodic oral evaluation - established patient |
3,690 |
3,651 |
$112K |
| D1120 |
Prophylaxis - child |
2,145 |
2,115 |
$93K |
| D1351 |
Sealant - per tooth |
2,428 |
573 |
$80K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
802 |
775 |
$42K |
| D0274 |
Bitewings - four radiographic images |
1,774 |
1,740 |
$41K |
| D0330 |
Panoramic radiographic image |
743 |
731 |
$32K |
| D1330 |
|
1,971 |
1,940 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,159 |
1,127 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
761 |
745 |
$6K |
| D0272 |
Bitewings - two radiographic images |
189 |
188 |
$3K |