| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,363 |
3,316 |
$134K |
| D1110 |
Prophylaxis - adult |
1,768 |
1,725 |
$79K |
| D0330 |
Panoramic radiographic image |
660 |
657 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
747 |
278 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
599 |
259 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
271 |
270 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,905 |
3,828 |
$5K |
| D1351 |
Sealant - per tooth |
3,555 |
1,059 |
$5K |
| D1120 |
Prophylaxis - child |
2,109 |
2,075 |
$5K |
| D1330 |
|
3,914 |
3,837 |
$2K |
| D0274 |
Bitewings - four radiographic images |
1,234 |
1,217 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
2,426 |
2,387 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,335 |
2,298 |
$672.55 |
| D0272 |
Bitewings - two radiographic images |
836 |
823 |
$547.04 |
| D3120 |
|
37 |
12 |
$0.00 |