| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,482 |
2,424 |
$75K |
| D1110 |
Prophylaxis - adult |
1,250 |
1,217 |
$61K |
| D1120 |
Prophylaxis - child |
1,330 |
1,302 |
$50K |
| D1206 |
Topical application of fluoride varnish |
2,664 |
2,607 |
$44K |
| D0274 |
Bitewings - four radiographic images |
599 |
582 |
$16K |
| D1351 |
Sealant - per tooth |
652 |
114 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
104 |
68 |
$9K |
| D0330 |
Panoramic radiographic image |
141 |
139 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
173 |
164 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
61 |
59 |
$3K |
| D1354 |
|
103 |
25 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
294 |
195 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
20 |
$2K |
| D0272 |
Bitewings - two radiographic images |
113 |
112 |
$2K |