| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,645 |
2,615 |
$127K |
| D0120 |
Periodic oral evaluation - established patient |
4,101 |
4,050 |
$112K |
| D0330 |
Panoramic radiographic image |
1,811 |
1,775 |
$102K |
| D1120 |
Prophylaxis - child |
2,117 |
2,091 |
$74K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,905 |
2,865 |
$56K |
| D0210 |
Intraoral - complete series of radiographic images |
550 |
543 |
$33K |
| D1351 |
Sealant - per tooth |
995 |
237 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,200 |
1,183 |
$25K |
| D1206 |
Topical application of fluoride varnish |
623 |
617 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
129 |
79 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
95 |
89 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
36 |
25 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$195.00 |