| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,842 |
1,802 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
403 |
235 |
$46K |
| D1120 |
Prophylaxis - child |
1,108 |
1,084 |
$46K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
285 |
154 |
$40K |
| D1110 |
Prophylaxis - adult |
659 |
648 |
$38K |
| D1206 |
Topical application of fluoride varnish |
1,117 |
1,085 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
710 |
702 |
$16K |
| D0274 |
Bitewings - four radiographic images |
714 |
706 |
$16K |
| D1351 |
Sealant - per tooth |
429 |
68 |
$13K |
| D0272 |
Bitewings - two radiographic images |
449 |
440 |
$7K |
| D1330 |
|
560 |
542 |
$3K |
| D0330 |
Panoramic radiographic image |
71 |
69 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
159 |
155 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
102 |
102 |
$624.00 |