| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,067 |
4,055 |
$109K |
| D1110 |
Prophylaxis - adult |
3,969 |
3,962 |
$87K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,316 |
1,315 |
$35K |
| D1351 |
Sealant - per tooth |
2,568 |
346 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
716 |
420 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,300 |
3,380 |
$26K |
| D1120 |
Prophylaxis - child |
892 |
892 |
$19K |
| D4355 |
|
311 |
308 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
517 |
517 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
3,673 |
3,649 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,597 |
1,596 |
$14K |
| D0272 |
Bitewings - two radiographic images |
2,717 |
2,709 |
$13K |
| D0602 |
|
313 |
313 |
$3K |
| D2335 |
|
39 |
26 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
121 |
121 |
$3K |
| D0603 |
|
148 |
148 |
$1K |
| D2950 |
|
19 |
14 |
$1K |