| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
765 |
730 |
$20K |
| D1206 |
Topical application of fluoride varnish |
935 |
887 |
$13K |
| D1120 |
Prophylaxis - child |
285 |
269 |
$9K |
| D1110 |
Prophylaxis - adult |
141 |
133 |
$7K |
| D0274 |
Bitewings - four radiographic images |
190 |
180 |
$5K |
| D0272 |
Bitewings - two radiographic images |
141 |
133 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
269 |
254 |
$3K |
| D1351 |
Sealant - per tooth |
77 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
149 |
128 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$423.84 |
| D0603 |
|
694 |
674 |
$0.00 |
| D0602 |
|
938 |
889 |
$0.00 |