| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,772 |
1,728 |
$43K |
| D1110 |
Prophylaxis - adult |
827 |
796 |
$34K |
| D0330 |
Panoramic radiographic image |
631 |
608 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,223 |
1,197 |
$23K |
| D1120 |
Prophylaxis - child |
756 |
736 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
1,328 |
1,257 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,249 |
760 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
261 |
246 |
$10K |
| D0272 |
Bitewings - two radiographic images |
527 |
516 |
$10K |
| D1351 |
Sealant - per tooth |
190 |
57 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$242.90 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$165.00 |