| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,379 |
4,371 |
$239K |
| D1110 |
Prophylaxis - adult |
2,673 |
2,664 |
$222K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,001 |
1,563 |
$162K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,324 |
1,313 |
$156K |
| D1120 |
Prophylaxis - child |
3,423 |
3,416 |
$129K |
| D9110 |
|
2,027 |
1,966 |
$127K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,973 |
1,966 |
$122K |
| D1351 |
Sealant - per tooth |
3,843 |
1,177 |
$105K |
| D0274 |
Bitewings - four radiographic images |
4,839 |
4,826 |
$102K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,452 |
6,390 |
$70K |
| D2330 |
|
536 |
270 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,815 |
2,807 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
2,240 |
2,187 |
$26K |
| D0272 |
Bitewings - two radiographic images |
555 |
554 |
$6K |
| D0350 |
|
32 |
28 |
$518.40 |