| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
793 |
785 |
$21K |
| D0350 |
|
746 |
738 |
$13K |
| D1110 |
Prophylaxis - adult |
235 |
233 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
830 |
815 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
796 |
786 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
799 |
757 |
$8K |
| D0274 |
Bitewings - four radiographic images |
236 |
233 |
$8K |
| D1120 |
Prophylaxis - child |
213 |
212 |
$7K |
| D0460 |
|
585 |
581 |
$7K |
| D0272 |
Bitewings - two radiographic images |
125 |
125 |
$3K |
| D1351 |
Sealant - per tooth |
139 |
22 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
15 |
$529.80 |
| D0603 |
|
999 |
975 |
$0.00 |