| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
752 |
729 |
$17K |
| D1120 |
Prophylaxis - child |
386 |
377 |
$16K |
| D1206 |
Topical application of fluoride varnish |
840 |
809 |
$11K |
| D1110 |
Prophylaxis - adult |
180 |
168 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
113 |
69 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
25 |
$4K |
| D1351 |
Sealant - per tooth |
207 |
52 |
$3K |
| D0330 |
Panoramic radiographic image |
91 |
90 |
$3K |
| D0274 |
Bitewings - four radiographic images |
74 |
74 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
72 |
71 |
$1K |
| D0272 |
Bitewings - two radiographic images |
64 |
64 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
43 |
41 |
$871.25 |
| D0220 |
Intraoral - periapical first radiographic image |
91 |
91 |
$828.36 |
| D0230 |
Intraoral - periapical each additional radiographic image |
83 |
42 |
$561.60 |