| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,411 |
1,399 |
$62K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,248 |
490 |
$59K |
| D1110 |
Prophylaxis - adult |
1,272 |
1,252 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
2,058 |
2,034 |
$32K |
| D0330 |
Panoramic radiographic image |
339 |
332 |
$22K |
| D0274 |
Bitewings - four radiographic images |
971 |
956 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
438 |
429 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,704 |
2,668 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
25 |
15 |
$4K |
| D1330 |
|
2,626 |
2,592 |
$2K |
| D1351 |
Sealant - per tooth |
108 |
29 |
$1K |
| D0272 |
Bitewings - two radiographic images |
813 |
807 |
$528.63 |