| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
938 |
915 |
$26K |
| D1351 |
Sealant - per tooth |
968 |
135 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,904 |
947 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,258 |
1,227 |
$18K |
| D1110 |
Prophylaxis - adult |
302 |
298 |
$16K |
| D1120 |
Prophylaxis - child |
453 |
443 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
157 |
47 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,101 |
1,075 |
$13K |
| D0274 |
Bitewings - four radiographic images |
353 |
348 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
24 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
36 |
12 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
73 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
13 |
$833.56 |
| D0603 |
|
1,685 |
1,662 |
$0.01 |