| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,011 |
975 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
274 |
85 |
$25K |
| D1110 |
Prophylaxis - adult |
402 |
388 |
$21K |
| D1120 |
Prophylaxis - child |
480 |
465 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,165 |
1,129 |
$16K |
| D0274 |
Bitewings - four radiographic images |
264 |
255 |
$9K |
| D0272 |
Bitewings - two radiographic images |
171 |
166 |
$4K |
| D1351 |
Sealant - per tooth |
124 |
26 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$931.72 |
| D0230 |
Intraoral - periapical each additional radiographic image |
67 |
29 |
$608.50 |
| D0220 |
Intraoral - periapical first radiographic image |
47 |
46 |
$565.98 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$495.92 |
| D0602 |
|
1,438 |
1,407 |
$0.00 |