| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,547 |
2,379 |
$65K |
| D1110 |
Prophylaxis - adult |
1,251 |
1,159 |
$58K |
| D1120 |
Prophylaxis - child |
1,517 |
1,429 |
$50K |
| D0274 |
Bitewings - four radiographic images |
1,315 |
1,216 |
$39K |
| D1351 |
Sealant - per tooth |
1,637 |
315 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,598 |
2,445 |
$34K |
| D0272 |
Bitewings - two radiographic images |
1,387 |
1,313 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
372 |
185 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
107 |
55 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
813 |
383 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
456 |
422 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
74 |
70 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
117 |
114 |
$2K |
| D0330 |
Panoramic radiographic image |
16 |
13 |
$187.07 |
| D1330 |
|
19 |
17 |
$159.25 |
| D0603 |
|
3,151 |
2,947 |
$0.00 |