| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
841 |
833 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,187 |
1,177 |
$43K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
408 |
236 |
$31K |
| D1110 |
Prophylaxis - adult |
696 |
691 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
685 |
680 |
$10K |
| D1120 |
Prophylaxis - child |
1,170 |
1,162 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,962 |
1,948 |
$6K |
| D1330 |
|
1,967 |
1,953 |
$4K |
| D1351 |
Sealant - per tooth |
355 |
62 |
$3K |
| D0272 |
Bitewings - two radiographic images |
1,721 |
1,709 |
$3K |
| D1999 |
|
13 |
13 |
$520.00 |
| D0601 |
|
571 |
566 |
$5.00 |