| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
629 |
615 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,719 |
792 |
$17K |
| D1120 |
Prophylaxis - child |
431 |
419 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
918 |
891 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
878 |
846 |
$10K |
| D1110 |
Prophylaxis - adult |
200 |
197 |
$9K |
| D0274 |
Bitewings - four radiographic images |
215 |
211 |
$6K |
| D1351 |
Sealant - per tooth |
218 |
43 |
$6K |
| D0272 |
Bitewings - two radiographic images |
194 |
190 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
53 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$2K |
| D0603 |
|
1,208 |
1,184 |
$0.00 |