| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
764 |
737 |
$25K |
| D1206 |
Topical application of fluoride varnish |
804 |
770 |
$22K |
| D1120 |
Prophylaxis - child |
515 |
499 |
$18K |
| D1110 |
Prophylaxis - adult |
192 |
183 |
$9K |
| D0274 |
Bitewings - four radiographic images |
99 |
93 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
69 |
$2K |
| D4999 |
|
132 |
95 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
41 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
16 |
15 |
$760.50 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
24 |
$365.78 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$257.40 |