| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,003 |
4,002 |
$112K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,277 |
658 |
$89K |
| D1120 |
Prophylaxis - child |
2,622 |
2,620 |
$81K |
| D1351 |
Sealant - per tooth |
3,175 |
550 |
$73K |
| D1110 |
Prophylaxis - adult |
1,754 |
1,752 |
$65K |
| D0330 |
Panoramic radiographic image |
1,275 |
1,273 |
$48K |
| D1206 |
Topical application of fluoride varnish |
2,053 |
2,051 |
$43K |
| D0274 |
Bitewings - four radiographic images |
2,587 |
2,583 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
5,136 |
5,031 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,397 |
4,326 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
501 |
499 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
924 |
924 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
209 |
140 |
$12K |
| D0272 |
Bitewings - two radiographic images |
1,033 |
1,030 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
345 |
342 |
$7K |
| D0603 |
|
12 |
12 |
$120.00 |
| D1330 |
|
1,361 |
1,255 |
$0.00 |