| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,471 |
1,445 |
$40K |
| D1351 |
Sealant - per tooth |
1,515 |
265 |
$38K |
| D1120 |
Prophylaxis - child |
1,059 |
1,043 |
$37K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,396 |
1,574 |
$24K |
| D1110 |
Prophylaxis - adult |
503 |
492 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,565 |
1,537 |
$22K |
| D0274 |
Bitewings - four radiographic images |
809 |
795 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,774 |
1,747 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
176 |
89 |
$16K |
| D0272 |
Bitewings - two radiographic images |
502 |
492 |
$11K |
| D0145 |
Oral evaluation for a patient under three years of age |
68 |
68 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
261 |
257 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
153 |
152 |
$502.27 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$93.84 |
| D0601 |
|
647 |
639 |
$0.00 |
| D0603 |
|
1,200 |
1,182 |
$0.00 |