| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
915 |
907 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
750 |
404 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
659 |
654 |
$43K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
762 |
417 |
$41K |
| D1120 |
Prophylaxis - child |
803 |
793 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,750 |
1,677 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
2,100 |
1,852 |
$25K |
| D9430 |
|
708 |
631 |
$23K |
| D0350 |
|
1,983 |
826 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,136 |
1,123 |
$14K |
| D1110 |
Prophylaxis - adult |
102 |
99 |
$9K |
| D1351 |
Sealant - per tooth |
133 |
45 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$1K |
| D4910 |
|
13 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$237.60 |