| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
703 |
693 |
$19K |
| D1110 |
Prophylaxis - adult |
259 |
252 |
$13K |
| D1120 |
Prophylaxis - child |
374 |
373 |
$13K |
| D1206 |
Topical application of fluoride varnish |
867 |
851 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
907 |
889 |
$11K |
| D1351 |
Sealant - per tooth |
390 |
94 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
877 |
846 |
$10K |
| D0274 |
Bitewings - four radiographic images |
280 |
274 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
24 |
$5K |
| D0272 |
Bitewings - two radiographic images |
204 |
204 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
98 |
92 |
$3K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
70 |
69 |
$911.40 |
| D0603 |
|
1,096 |
1,079 |
$0.04 |
| D0602 |
|
52 |
51 |
$0.00 |