| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,531 |
1,522 |
$29K |
| D1110 |
Prophylaxis - adult |
619 |
619 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,353 |
1,345 |
$27K |
| D1120 |
Prophylaxis - child |
608 |
602 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
27 |
$5K |
| D0274 |
Bitewings - four radiographic images |
88 |
88 |
$2K |
| D1351 |
Sealant - per tooth |
49 |
14 |
$1K |
| D0330 |
Panoramic radiographic image |
22 |
22 |
$1K |
| D0251 |
|
12 |
12 |
$566.28 |
| D0220 |
Intraoral - periapical first radiographic image |
40 |
39 |
$436.02 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$347.62 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$282.10 |