| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
950 |
905 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
280 |
129 |
$23K |
| D0274 |
Bitewings - four radiographic images |
855 |
811 |
$19K |
| D1120 |
Prophylaxis - child |
597 |
565 |
$17K |
| D1110 |
Prophylaxis - adult |
371 |
355 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
653 |
626 |
$9K |
| D1351 |
Sealant - per tooth |
348 |
49 |
$6K |
| D1206 |
Topical application of fluoride varnish |
285 |
264 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
57 |
55 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
27 |
$864.64 |
| D0220 |
Intraoral - periapical first radiographic image |
53 |
46 |
$468.46 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$347.67 |
| D0230 |
Intraoral - periapical each additional radiographic image |
46 |
13 |
$344.15 |
| D0601 |
|
628 |
589 |
$0.00 |
| D0602 |
|
137 |
129 |
$0.00 |
| D0603 |
|
12 |
12 |
$0.00 |