| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,880 |
2,873 |
$128K |
| D1110 |
Prophylaxis - adult |
2,295 |
2,290 |
$127K |
| D0274 |
Bitewings - four radiographic images |
2,535 |
2,530 |
$84K |
| D0220 |
Intraoral - periapical first radiographic image |
2,584 |
2,547 |
$38K |
| D1206 |
Topical application of fluoride varnish |
1,055 |
1,053 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,217 |
2,206 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,087 |
1,086 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
250 |
166 |
$27K |
| D1120 |
Prophylaxis - child |
590 |
589 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
50 |
$7K |
| D1351 |
Sealant - per tooth |
107 |
18 |
$5K |
| D0272 |
Bitewings - two radiographic images |
86 |
86 |
$3K |
| D8670 |
Periodic orthodontic treatment visit |
21 |
21 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$540.00 |