| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,613 |
3,611 |
$181K |
| D1120 |
Prophylaxis - child |
4,181 |
4,171 |
$148K |
| D1351 |
Sealant - per tooth |
4,121 |
1,360 |
$105K |
| D1206 |
Topical application of fluoride varnish |
4,131 |
4,123 |
$46K |
| D0272 |
Bitewings - two radiographic images |
2,032 |
2,029 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
173 |
114 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
71 |
71 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
42 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
26 |
$728.00 |
| D1310 |
|
12 |
12 |
$506.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
24 |
$117.90 |