| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,268 |
2,258 |
$126K |
| D1120 |
Prophylaxis - child |
2,692 |
2,682 |
$103K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,776 |
2,763 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,550 |
1,542 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,704 |
2,564 |
$23K |
| D1351 |
Sealant - per tooth |
692 |
187 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
171 |
80 |
$11K |
| D0272 |
Bitewings - two radiographic images |
394 |
394 |
$5K |
| D0350 |
|
454 |
174 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
45 |
$3K |
| D9993 |
|
38 |
37 |
$2K |
| D1310 |
|
38 |
37 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
12 |
$1K |