| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
10,539 |
10,317 |
$269K |
| D1110 |
Prophylaxis - adult |
7,012 |
6,788 |
$263K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,371 |
1,383 |
$250K |
| D0274 |
Bitewings - four radiographic images |
4,412 |
4,202 |
$132K |
| D1206 |
Topical application of fluoride varnish |
7,763 |
7,554 |
$127K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,582 |
1,040 |
$127K |
| D0330 |
Panoramic radiographic image |
2,519 |
2,346 |
$125K |
| D1120 |
Prophylaxis - child |
4,596 |
4,465 |
$122K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,463 |
3,966 |
$86K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,206 |
2,034 |
$86K |
| D0220 |
Intraoral - periapical first radiographic image |
6,089 |
5,514 |
$86K |
| D0140 |
Limited oral evaluation - problem focused |
1,577 |
1,458 |
$53K |
| D0272 |
Bitewings - two radiographic images |
1,201 |
1,176 |
$22K |
| D1351 |
Sealant - per tooth |
705 |
178 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
820 |
808 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$2K |
| D2331 |
|
24 |
12 |
$2K |
| D4355 |
|
16 |
13 |
$912.72 |