| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,315 |
1,293 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,309 |
1,289 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
852 |
839 |
$20K |
| D0330 |
Panoramic radiographic image |
546 |
540 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
177 |
169 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
438 |
423 |
$11K |
| D0274 |
Bitewings - four radiographic images |
622 |
617 |
$8K |
| D1351 |
Sealant - per tooth |
79 |
64 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
169 |
169 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
66 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
202 |
198 |
$4K |
| D1110 |
Prophylaxis - adult |
83 |
82 |
$4K |
| D0272 |
Bitewings - two radiographic images |
174 |
168 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
253 |
248 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
103 |
102 |
$402.80 |