| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,031 |
1,025 |
$55K |
| D1110 |
Prophylaxis - adult |
682 |
675 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
221 |
221 |
$14K |
| D1120 |
Prophylaxis - child |
663 |
660 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
25 |
$3K |
| D1330 |
|
1,425 |
1,415 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,436 |
1,426 |
$1K |
| D1351 |
Sealant - per tooth |
1,126 |
288 |
$491.92 |
| D0274 |
Bitewings - four radiographic images |
698 |
694 |
$230.33 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
37 |
37 |
$0.00 |
| D3120 |
|
23 |
12 |
$0.00 |