| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,747 |
3,705 |
$129K |
| D1110 |
Prophylaxis - adult |
1,543 |
1,529 |
$83K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
711 |
366 |
$44K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
885 |
882 |
$38K |
| D1120 |
Prophylaxis - child |
3,066 |
3,042 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
372 |
194 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,547 |
4,508 |
$9K |
| D1330 |
|
4,668 |
4,625 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
181 |
176 |
$2K |
| D0274 |
Bitewings - four radiographic images |
738 |
731 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
1,505 |
1,464 |
$883.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,298 |
1,241 |
$617.03 |
| D0272 |
Bitewings - two radiographic images |
340 |
339 |
$505.02 |
| D1351 |
Sealant - per tooth |
45 |
13 |
$309.12 |
| D1206 |
Topical application of fluoride varnish |
57 |
57 |
$0.00 |
| D1999 |
|
21 |
19 |
$0.00 |