| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
902 |
874 |
$44K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
182 |
96 |
$11K |
| D1110 |
Prophylaxis - adult |
699 |
683 |
$9K |
| D1120 |
Prophylaxis - child |
399 |
385 |
$7K |
| D0330 |
Panoramic radiographic image |
176 |
173 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
96 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,167 |
1,130 |
$2K |
| D0274 |
Bitewings - four radiographic images |
1,148 |
1,112 |
$2K |
| D1330 |
|
1,208 |
1,173 |
$460.86 |
| D0220 |
Intraoral - periapical first radiographic image |
1,267 |
1,218 |
$458.05 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,195 |
1,158 |
$307.81 |
| D1351 |
Sealant - per tooth |
325 |
87 |
$104.98 |