| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
869 |
814 |
$23K |
| D1120 |
Prophylaxis - child |
834 |
778 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,525 |
1,415 |
$16K |
| D1330 |
|
1,331 |
1,237 |
$16K |
| D1110 |
Prophylaxis - adult |
446 |
407 |
$15K |
| D0274 |
Bitewings - four radiographic images |
373 |
332 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
85 |
26 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
82 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
385 |
344 |
$3K |
| D0330 |
Panoramic radiographic image |
57 |
54 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
390 |
215 |
$2K |
| D9630 |
|
29 |
26 |
$1K |
| D1351 |
Sealant - per tooth |
50 |
14 |
$800.00 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$500.00 |