| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,286 |
2,141 |
$55K |
| D1206 |
Topical application of fluoride varnish |
2,015 |
1,887 |
$31K |
| D1120 |
Prophylaxis - child |
1,162 |
1,108 |
$30K |
| 99199 |
Unlisted special service, procedure or report |
7,652 |
7,528 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,528 |
1,448 |
$22K |
| D1110 |
Prophylaxis - adult |
481 |
453 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,217 |
997 |
$14K |
| D0274 |
Bitewings - four radiographic images |
230 |
212 |
$6K |
| D1351 |
Sealant - per tooth |
178 |
43 |
$5K |
| D0272 |
Bitewings - two radiographic images |
269 |
260 |
$5K |
| D0330 |
Panoramic radiographic image |
134 |
128 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
54 |
40 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
13 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$1K |
| D1330 |
|
704 |
674 |
$0.00 |
| D0603 |
|
13 |
13 |
$0.00 |
| D0601 |
|
46 |
44 |
$0.00 |