| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,248 |
1,246 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,090 |
1,089 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,232 |
1,230 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
241 |
129 |
$23K |
| D0272 |
Bitewings - two radiographic images |
801 |
801 |
$21K |
| D0274 |
Bitewings - four radiographic images |
256 |
255 |
$10K |
| D1351 |
Sealant - per tooth |
283 |
55 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
199 |
198 |
$8K |
| D0330 |
Panoramic radiographic image |
92 |
92 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
405 |
400 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
64 |
39 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
264 |
246 |
$3K |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$793.64 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$503.25 |