| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
847 |
824 |
$21K |
| D1110 |
Prophylaxis - adult |
305 |
301 |
$15K |
| D0350 |
|
733 |
718 |
$12K |
| D0274 |
Bitewings - four radiographic images |
380 |
372 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
750 |
732 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
748 |
732 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
748 |
729 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
21 |
$6K |
| D0460 |
|
502 |
497 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
53 |
18 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
54 |
21 |
$4K |
| D1120 |
Prophylaxis - child |
134 |
129 |
$4K |
| D0272 |
Bitewings - two radiographic images |
103 |
101 |
$2K |
| D1351 |
Sealant - per tooth |
111 |
12 |
$818.96 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$141.28 |
| D0603 |
|
1,031 |
1,004 |
$0.00 |