| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,056 |
2,036 |
$105K |
| D1120 |
Prophylaxis - child |
2,266 |
2,247 |
$85K |
| D1110 |
Prophylaxis - adult |
896 |
883 |
$77K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,031 |
3,630 |
$32K |
| D0272 |
Bitewings - two radiographic images |
2,062 |
2,040 |
$24K |
| D1351 |
Sealant - per tooth |
825 |
207 |
$21K |
| D0274 |
Bitewings - four radiographic images |
972 |
962 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
821 |
804 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
122 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
180 |
177 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$873.60 |
| D0350 |
|
80 |
45 |
$681.60 |
| D1203 |
|
61 |
53 |
$40.00 |
| D1999 |
|
107 |
107 |
$0.00 |