| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,410 |
1,376 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
382 |
197 |
$23K |
| D1110 |
Prophylaxis - adult |
619 |
615 |
$21K |
| D1120 |
Prophylaxis - child |
1,134 |
1,089 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
237 |
121 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
98 |
98 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
640 |
626 |
$4K |
| D1330 |
|
1,778 |
1,730 |
$3K |
| D0274 |
Bitewings - four radiographic images |
490 |
487 |
$3K |
| D1206 |
Topical application of fluoride varnish |
812 |
789 |
$3K |
| D0272 |
Bitewings - two radiographic images |
491 |
474 |
$2K |
| D1351 |
Sealant - per tooth |
261 |
84 |
$2K |
| D3120 |
|
279 |
148 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
1,186 |
1,146 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,125 |
1,075 |
$1K |
| D9920 |
|
41 |
30 |
$758.30 |
| D0145 |
Oral evaluation for a patient under three years of age |
19 |
19 |
$327.28 |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
15 |
$0.00 |