| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,662 |
5,604 |
$148K |
| D1120 |
Prophylaxis - child |
3,025 |
3,004 |
$134K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,091 |
6,048 |
$133K |
| D1110 |
Prophylaxis - adult |
3,100 |
3,076 |
$108K |
| D0274 |
Bitewings - four radiographic images |
2,409 |
2,392 |
$80K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,019 |
632 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
753 |
569 |
$59K |
| D0210 |
Intraoral - complete series of radiographic images |
593 |
588 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,163 |
1,613 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
627 |
620 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
125 |
92 |
$11K |
| D0272 |
Bitewings - two radiographic images |
304 |
304 |
$9K |
| D1351 |
Sealant - per tooth |
155 |
52 |
$6K |
| D2330 |
|
19 |
14 |
$1K |
| D2140 |
|
21 |
14 |
$997.88 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$127.30 |