| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,475 |
2,473 |
$49K |
| D1120 |
Prophylaxis - child |
346 |
343 |
$13K |
| D1206 |
Topical application of fluoride varnish |
345 |
345 |
$12K |
| T1015 |
Clinic visit/encounter, all-inclusive |
139 |
98 |
$12K |
| D0274 |
Bitewings - four radiographic images |
301 |
300 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
88 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
59 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
146 |
146 |
$4K |
| D1351 |
Sealant - per tooth |
192 |
70 |
$4K |
| D0330 |
Panoramic radiographic image |
47 |
47 |
$2K |
| D1110 |
Prophylaxis - adult |
118 |
93 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
116 |
115 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
55 |
$1K |
| D7111 |
|
15 |
12 |
$750.00 |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$720.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
75 |
75 |
$632.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
38 |
$55.40 |