| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,456 |
3,153 |
$135K |
| D1206 |
Topical application of fluoride varnish |
3,211 |
2,924 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
2,709 |
2,433 |
$79K |
| D0274 |
Bitewings - four radiographic images |
813 |
721 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
269 |
252 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
147 |
94 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
57 |
$11K |
| D0330 |
Panoramic radiographic image |
124 |
96 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
331 |
309 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
178 |
162 |
$3K |
| D1351 |
Sealant - per tooth |
59 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
65 |
65 |
$2K |
| D1999 |
|
24 |
23 |
$0.00 |