| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,049 |
3,653 |
$78K |
| D1120 |
Prophylaxis - child |
3,093 |
2,794 |
$76K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,156 |
3,755 |
$67K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
945 |
400 |
$61K |
| D1110 |
Prophylaxis - adult |
1,436 |
1,291 |
$53K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
305 |
155 |
$21K |
| D0272 |
Bitewings - two radiographic images |
1,128 |
1,004 |
$21K |
| D0330 |
Panoramic radiographic image |
330 |
311 |
$17K |
| D1351 |
Sealant - per tooth |
331 |
70 |
$7K |
| D0274 |
Bitewings - four radiographic images |
147 |
131 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
56 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
14 |
$151.14 |