| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
849 |
844 |
$23K |
| D1120 |
Prophylaxis - child |
517 |
515 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
967 |
963 |
$13K |
| D1110 |
Prophylaxis - adult |
208 |
198 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
24 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
319 |
305 |
$3K |
| D0274 |
Bitewings - four radiographic images |
101 |
98 |
$3K |
| D1351 |
Sealant - per tooth |
107 |
19 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
194 |
181 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$945.63 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
24 |
24 |
$671.08 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$537.74 |
| D0603 |
|
569 |
559 |
$0.00 |
| D0602 |
|
156 |
156 |
$0.00 |