| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,493 |
6,320 |
$264K |
| D0120 |
Periodic oral evaluation - established patient |
6,969 |
6,777 |
$190K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,398 |
6,238 |
$165K |
| D1351 |
Sealant - per tooth |
1,306 |
752 |
$108K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
919 |
681 |
$76K |
| D0274 |
Bitewings - four radiographic images |
2,876 |
2,787 |
$51K |
| D1110 |
Prophylaxis - adult |
366 |
343 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
200 |
196 |
$5K |
| D0272 |
Bitewings - two radiographic images |
274 |
260 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
61 |
61 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
12 |
$928.80 |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$756.00 |
| D1354 |
|
24 |
13 |
$519.75 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
13 |
$72.80 |
| D1999 |
|
114 |
113 |
$0.00 |