| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,392 |
1,390 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,531 |
1,527 |
$30K |
| D1120 |
Prophylaxis - child |
982 |
981 |
$26K |
| D1110 |
Prophylaxis - adult |
404 |
402 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
244 |
163 |
$14K |
| D1351 |
Sealant - per tooth |
411 |
84 |
$11K |
| D0272 |
Bitewings - two radiographic images |
554 |
552 |
$10K |
| D0274 |
Bitewings - four radiographic images |
277 |
276 |
$8K |
| D0603 |
|
482 |
481 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
52 |
$3K |
| D1330 |
|
627 |
625 |
$3K |
| D0330 |
Panoramic radiographic image |
67 |
67 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
95 |
$2K |
| D1310 |
|
87 |
87 |
$901.00 |
| D0220 |
Intraoral - periapical first radiographic image |
50 |
50 |
$422.55 |
| D0602 |
|
43 |
43 |
$420.00 |
| D0240 |
|
12 |
12 |
$283.60 |