| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,541 |
2,530 |
$72K |
| D1110 |
Prophylaxis - adult |
1,145 |
1,139 |
$62K |
| D1120 |
Prophylaxis - child |
1,713 |
1,705 |
$62K |
| D0274 |
Bitewings - four radiographic images |
1,157 |
1,152 |
$37K |
| D0272 |
Bitewings - two radiographic images |
1,550 |
1,541 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
410 |
167 |
$31K |
| D0145 |
Oral evaluation for a patient under three years of age |
204 |
200 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,615 |
1,605 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,190 |
1,188 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
156 |
77 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
895 |
856 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
110 |
110 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
421 |
162 |
$3K |
| D0602 |
|
1,464 |
1,458 |
$0.00 |
| D0603 |
|
499 |
496 |
$0.00 |
| D0601 |
|
1,171 |
1,167 |
$0.00 |