| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,258 |
2,253 |
$42K |
| D1120 |
Prophylaxis - child |
1,829 |
1,829 |
$34K |
| D1110 |
Prophylaxis - adult |
783 |
779 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,869 |
1,865 |
$14K |
| D0274 |
Bitewings - four radiographic images |
1,226 |
1,226 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,721 |
1,707 |
$6K |
| D1351 |
Sealant - per tooth |
599 |
100 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
298 |
298 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,612 |
1,604 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
121 |
121 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
37 |
$2K |
| D0330 |
Panoramic radiographic image |
120 |
120 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
73 |
73 |
$1K |
| D0272 |
Bitewings - two radiographic images |
138 |
138 |
$690.00 |