| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
611 |
540 |
$14K |
| D4341 |
|
358 |
121 |
$14K |
| D1206 |
Topical application of fluoride varnish |
741 |
590 |
$11K |
| D1354 |
|
2,506 |
415 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
278 |
229 |
$7K |
| D0274 |
Bitewings - four radiographic images |
314 |
267 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
614 |
501 |
$5K |
| D1120 |
Prophylaxis - child |
147 |
127 |
$5K |
| D4910 |
|
93 |
91 |
$5K |
| D1110 |
Prophylaxis - adult |
94 |
94 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
27 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
108 |
53 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
21 |
$2K |
| D9630 |
|
668 |
507 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
250 |
130 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$816.00 |
| D4355 |
|
26 |
13 |
$378.00 |
| D0602 |
|
13 |
13 |
$130.00 |
| D1330 |
|
772 |
573 |
$30.00 |
| D1310 |
|
75 |
64 |
$0.00 |