| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,921 |
1,900 |
$103K |
| D1120 |
Prophylaxis - child |
2,446 |
2,417 |
$95K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
613 |
370 |
$41K |
| D0274 |
Bitewings - four radiographic images |
1,534 |
1,521 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,714 |
2,553 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,508 |
2,480 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
173 |
165 |
$11K |
| D0272 |
Bitewings - two radiographic images |
302 |
296 |
$4K |
| D1351 |
Sealant - per tooth |
78 |
24 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
12 |
$156.00 |