| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,371 |
2,360 |
$122K |
| D1120 |
Prophylaxis - child |
2,714 |
2,700 |
$102K |
| D0274 |
Bitewings - four radiographic images |
1,896 |
1,889 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,898 |
2,725 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,780 |
1,772 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
54 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
387 |
379 |
$4K |
| D1351 |
Sealant - per tooth |
114 |
26 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$4K |
| D0272 |
Bitewings - two radiographic images |
295 |
293 |
$3K |
| D0350 |
|
56 |
26 |
$384.00 |
| D9993 |
|
21 |
21 |
$0.00 |
| D1310 |
|
21 |
21 |
$0.00 |
| D0601 |
|
14 |
14 |
$0.00 |