| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,224 |
1,191 |
$31K |
| D0274 |
Bitewings - four radiographic images |
1,119 |
1,091 |
$23K |
| D1120 |
Prophylaxis - child |
1,171 |
1,141 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,520 |
1,473 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
187 |
133 |
$14K |
| D1110 |
Prophylaxis - adult |
378 |
365 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
141 |
108 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
180 |
171 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
560 |
315 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
602 |
575 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
193 |
179 |
$5K |
| D0330 |
Panoramic radiographic image |
206 |
205 |
$5K |
| D1351 |
Sealant - per tooth |
71 |
24 |
$2K |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$208.00 |