| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,576 |
5,492 |
$282K |
| D1351 |
Sealant - per tooth |
9,481 |
2,475 |
$204K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,022 |
3,985 |
$120K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,325 |
6,234 |
$93K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,241 |
5,588 |
$87K |
| D0272 |
Bitewings - two radiographic images |
4,411 |
4,336 |
$73K |
| D0220 |
Intraoral - periapical first radiographic image |
6,048 |
5,964 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
2,569 |
2,519 |
$56K |
| D1354 |
|
3,886 |
938 |
$33K |
| D1110 |
Prophylaxis - adult |
623 |
621 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
420 |
230 |
$26K |
| D0274 |
Bitewings - four radiographic images |
445 |
442 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
168 |
109 |
$7K |
| D0603 |
|
558 |
541 |
$0.00 |