| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,292 |
2,280 |
$131K |
| D1120 |
Prophylaxis - child |
3,023 |
3,005 |
$122K |
| D1351 |
Sealant - per tooth |
3,213 |
743 |
$94K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,992 |
2,974 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
353 |
353 |
$23K |
| D0274 |
Bitewings - four radiographic images |
1,073 |
1,062 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,542 |
2,286 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
160 |
115 |
$11K |
| D0272 |
Bitewings - two radiographic images |
729 |
726 |
$9K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
117 |
85 |
$8K |
| D1310 |
|
51 |
51 |
$2K |
| D0240 |
|
195 |
98 |
$2K |
| D1999 |
|
16 |
16 |
$0.00 |