| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,537 |
2,437 |
$61K |
| D1110 |
Prophylaxis - adult |
1,531 |
1,486 |
$56K |
| D1120 |
Prophylaxis - child |
956 |
925 |
$24K |
| D1206 |
Topical application of fluoride varnish |
1,355 |
1,320 |
$21K |
| D0274 |
Bitewings - four radiographic images |
610 |
594 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
370 |
341 |
$12K |
| D0330 |
Panoramic radiographic image |
197 |
189 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
231 |
220 |
$9K |
| D0272 |
Bitewings - two radiographic images |
202 |
192 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
238 |
217 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
12 |
$3K |
| D1351 |
Sealant - per tooth |
45 |
14 |
$979.82 |