| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,881 |
1,844 |
$79K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,613 |
2,568 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
1,905 |
1,872 |
$55K |
| D1351 |
Sealant - per tooth |
1,221 |
218 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
673 |
665 |
$34K |
| D1110 |
Prophylaxis - adult |
547 |
541 |
$32K |
| D0330 |
Panoramic radiographic image |
411 |
402 |
$17K |
| D0274 |
Bitewings - four radiographic images |
334 |
326 |
$7K |
| D0272 |
Bitewings - two radiographic images |
433 |
427 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
33 |
12 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
24 |
$5K |
| D1330 |
|
406 |
404 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
47 |
$432.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
35 |
35 |
$210.00 |