| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,939 |
1,899 |
$56K |
| D1120 |
Prophylaxis - child |
1,830 |
1,785 |
$53K |
| D1110 |
Prophylaxis - adult |
1,312 |
1,278 |
$49K |
| D1206 |
Topical application of fluoride varnish |
3,081 |
2,993 |
$36K |
| D0274 |
Bitewings - four radiographic images |
916 |
903 |
$18K |
| D1351 |
Sealant - per tooth |
584 |
85 |
$9K |
| D0272 |
Bitewings - two radiographic images |
357 |
350 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
28 |
$5K |
| D1330 |
|
377 |
372 |
$5K |
| D0330 |
Panoramic radiographic image |
65 |
65 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
43 |
$2K |
| D1354 |
|
37 |
12 |
$890.64 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
12 |
$280.00 |