| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,682 |
1,678 |
$93K |
| D1120 |
Prophylaxis - child |
1,071 |
1,067 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,889 |
1,656 |
$35K |
| D1206 |
Topical application of fluoride varnish |
2,013 |
2,004 |
$27K |
| D1110 |
Prophylaxis - adult |
268 |
268 |
$24K |
| D0274 |
Bitewings - four radiographic images |
942 |
937 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
273 |
139 |
$18K |
| D0350 |
|
1,621 |
736 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
62 |
62 |
$4K |
| D1351 |
Sealant - per tooth |
86 |
29 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
24 |
$2K |
| D1999 |
|
736 |
702 |
$325.25 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |