| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,465 |
1,450 |
$76K |
| D1120 |
Prophylaxis - child |
1,723 |
1,708 |
$64K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,317 |
1,838 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
646 |
302 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,794 |
1,779 |
$21K |
| D0274 |
Bitewings - four radiographic images |
525 |
523 |
$11K |
| D9993 |
|
27 |
27 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
36 |
36 |
$2K |
| D1351 |
Sealant - per tooth |
64 |
19 |
$1K |
| D1310 |
|
27 |
27 |
$1K |
| D0330 |
Panoramic radiographic image |
20 |
20 |
$570.00 |
| D0603 |
|
12 |
12 |
$180.00 |