| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,680 |
3,647 |
$198K |
| D1351 |
Sealant - per tooth |
6,847 |
1,844 |
$156K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,047 |
3,020 |
$95K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,032 |
4,003 |
$65K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,108 |
4,067 |
$63K |
| D0220 |
Intraoral - periapical first radiographic image |
4,088 |
4,058 |
$44K |
| D0272 |
Bitewings - two radiographic images |
2,495 |
2,471 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
1,277 |
1,267 |
$31K |
| D1110 |
Prophylaxis - adult |
328 |
325 |
$19K |
| D1354 |
|
1,746 |
528 |
$15K |
| D0274 |
Bitewings - four radiographic images |
278 |
276 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
108 |
59 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
37 |
$4K |
| D0603 |
|
245 |
236 |
$0.00 |