| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
822 |
751 |
$30K |
| D1120 |
Prophylaxis - child |
1,019 |
938 |
$27K |
| D0330 |
Panoramic radiographic image |
394 |
379 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
192 |
122 |
$17K |
| D1351 |
Sealant - per tooth |
632 |
132 |
$16K |
| D1206 |
Topical application of fluoride varnish |
536 |
502 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
300 |
274 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
95 |
61 |
$6K |
| D0272 |
Bitewings - two radiographic images |
268 |
243 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
120 |
112 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
180 |
162 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
149 |
127 |
$2K |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$701.82 |