| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
650 |
587 |
$12K |
| D1120 |
Prophylaxis - child |
382 |
332 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
96 |
40 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
115 |
44 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
648 |
573 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
786 |
681 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
718 |
621 |
$5K |
| D1351 |
Sealant - per tooth |
151 |
29 |
$4K |
| D0274 |
Bitewings - four radiographic images |
223 |
204 |
$4K |
| D1110 |
Prophylaxis - adult |
84 |
81 |
$4K |
| D0272 |
Bitewings - two radiographic images |
196 |
168 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
26 |
$775.72 |
| D1206 |
Topical application of fluoride varnish |
30 |
27 |
$294.00 |
| D1330 |
|
21 |
16 |
$12.25 |
| D0601 |
|
503 |
430 |
$0.00 |
| D0603 |
|
62 |
51 |
$0.00 |
| D0602 |
|
57 |
53 |
$0.00 |