| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,134 |
1,125 |
$32K |
| D1110 |
Prophylaxis - adult |
458 |
455 |
$24K |
| D1120 |
Prophylaxis - child |
672 |
667 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,346 |
1,335 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
541 |
538 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
533 |
530 |
$6K |
| D1351 |
Sealant - per tooth |
133 |
30 |
$4K |
| D0272 |
Bitewings - two radiographic images |
84 |
84 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
56 |
56 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
12 |
$433.20 |
| D0601 |
|
981 |
971 |
$0.00 |
| D0602 |
|
57 |
57 |
$0.00 |