| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
845 |
801 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,088 |
1,023 |
$24K |
| D1110 |
Prophylaxis - adult |
419 |
391 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
228 |
124 |
$16K |
| D0330 |
Panoramic radiographic image |
398 |
378 |
$15K |
| D1206 |
Topical application of fluoride varnish |
679 |
637 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
516 |
494 |
$10K |
| D0274 |
Bitewings - four radiographic images |
357 |
341 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
107 |
63 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
200 |
190 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
102 |
97 |
$2K |
| D1351 |
Sealant - per tooth |
59 |
17 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
153 |
145 |
$2K |
| D0272 |
Bitewings - two radiographic images |
107 |
100 |
$2K |