| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,066 |
2,029 |
$52K |
| D1206 |
Topical application of fluoride varnish |
1,985 |
1,950 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,572 |
1,542 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
554 |
541 |
$17K |
| D0272 |
Bitewings - two radiographic images |
772 |
745 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
104 |
52 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
275 |
272 |
$4K |
| D1351 |
Sealant - per tooth |
94 |
26 |
$2K |
| D0330 |
Panoramic radiographic image |
40 |
39 |
$2K |
| D1110 |
Prophylaxis - adult |
62 |
53 |
$2K |
| D0274 |
Bitewings - four radiographic images |
44 |
44 |
$840.00 |
| D0220 |
Intraoral - periapical first radiographic image |
47 |
46 |
$230.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$140.00 |