| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
306 |
294 |
$7K |
| D1120 |
Prophylaxis - child |
254 |
248 |
$6K |
| D1351 |
Sealant - per tooth |
226 |
69 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
318 |
308 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
29 |
$4K |
| D1110 |
Prophylaxis - adult |
86 |
81 |
$3K |
| D0272 |
Bitewings - two radiographic images |
97 |
96 |
$2K |
| D0330 |
Panoramic radiographic image |
15 |
13 |
$619.52 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
12 |
$451.22 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$424.10 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$198.52 |