| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,385 |
2,377 |
$85K |
| D1120 |
Prophylaxis - child |
2,377 |
2,375 |
$71K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,695 |
2,611 |
$39K |
| D1351 |
Sealant - per tooth |
1,702 |
426 |
$37K |
| D0272 |
Bitewings - two radiographic images |
2,503 |
2,499 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,606 |
2,603 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
125 |
61 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
13 |
$1K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$792.00 |