| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
745 |
740 |
$58K |
| D1120 |
Prophylaxis - child |
505 |
504 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
221 |
141 |
$12K |
| D0330 |
Panoramic radiographic image |
89 |
88 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
1,265 |
1,255 |
$3K |
| D1206 |
Topical application of fluoride varnish |
101 |
100 |
$1K |
| D0274 |
Bitewings - four radiographic images |
760 |
755 |
$1K |
| D1351 |
Sealant - per tooth |
340 |
88 |
$745.01 |
| D1208 |
Topical application of fluoride, excluding varnish |
1,213 |
1,207 |
$722.04 |
| D0272 |
Bitewings - two radiographic images |
441 |
440 |
$236.64 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
79 |
$168.94 |
| D1330 |
|
659 |
655 |
$145.27 |
| D0220 |
Intraoral - periapical first radiographic image |
200 |
198 |
$10.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
207 |
188 |
$8.00 |
| D0601 |
|
216 |
216 |
$5.00 |