| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
694 |
676 |
$17K |
| D1120 |
Prophylaxis - child |
487 |
480 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
180 |
90 |
$15K |
| D1110 |
Prophylaxis - adult |
222 |
214 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,185 |
791 |
$10K |
| D1351 |
Sealant - per tooth |
472 |
75 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
716 |
697 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
991 |
888 |
$9K |
| D0274 |
Bitewings - four radiographic images |
262 |
250 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
94 |
50 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
28 |
28 |
$4K |
| D0272 |
Bitewings - two radiographic images |
135 |
135 |
$3K |
| D0350 |
|
634 |
359 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
60 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
20 |
19 |
$1K |
| D1206 |
Topical application of fluoride varnish |
40 |
38 |
$529.20 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$160.32 |
| D0603 |
|
1,304 |
1,234 |
$0.00 |