| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9110 |
|
497 |
387 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
752 |
747 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,970 |
1,021 |
$21K |
| D1120 |
Prophylaxis - child |
707 |
693 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
190 |
190 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
146 |
81 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
142 |
71 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
448 |
439 |
$5K |
| D0272 |
Bitewings - two radiographic images |
434 |
428 |
$5K |
| D1351 |
Sealant - per tooth |
79 |
25 |
$2K |
| D9430 |
|
52 |
52 |
$2K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$1K |
| D0274 |
Bitewings - four radiographic images |
33 |
33 |
$691.20 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$126.00 |