| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,204 |
1,192 |
$35K |
| D1110 |
Prophylaxis - adult |
620 |
619 |
$24K |
| D1120 |
Prophylaxis - child |
729 |
728 |
$21K |
| D1206 |
Topical application of fluoride varnish |
1,440 |
1,420 |
$17K |
| D0330 |
Panoramic radiographic image |
332 |
330 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
77 |
$11K |
| D1351 |
Sealant - per tooth |
511 |
98 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
381 |
375 |
$7K |
| D0274 |
Bitewings - four radiographic images |
293 |
290 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
85 |
85 |
$5K |
| D0272 |
Bitewings - two radiographic images |
295 |
295 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
412 |
301 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$2K |
| D1354 |
|
47 |
14 |
$1K |