| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,526 |
2,513 |
$145K |
| D1120 |
Prophylaxis - child |
2,748 |
2,732 |
$108K |
| D1351 |
Sealant - per tooth |
2,473 |
626 |
$69K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15,758 |
3,542 |
$65K |
| D0274 |
Bitewings - four radiographic images |
2,441 |
2,429 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,018 |
3,001 |
$38K |
| D9430 |
|
1,074 |
1,047 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
305 |
145 |
$20K |
| D0330 |
Panoramic radiographic image |
416 |
416 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
168 |
166 |
$11K |
| D1110 |
Prophylaxis - adult |
55 |
55 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
358 |
312 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
41 |
28 |
$3K |
| D0272 |
Bitewings - two radiographic images |
222 |
221 |
$3K |
| D9993 |
|
25 |
25 |
$2K |
| D1310 |
|
25 |
25 |
$1K |
| D0601 |
|
25 |
25 |
$375.00 |
| D1999 |
|
121 |
115 |
$0.00 |