| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,016 |
2,009 |
$110K |
| D1120 |
Prophylaxis - child |
1,689 |
1,680 |
$63K |
| D1110 |
Prophylaxis - adult |
380 |
379 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,311 |
2,302 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,148 |
1,291 |
$16K |
| D0274 |
Bitewings - four radiographic images |
609 |
608 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
242 |
238 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
125 |
125 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
55 |
39 |
$4K |
| D0272 |
Bitewings - two radiographic images |
267 |
262 |
$3K |
| D1351 |
Sealant - per tooth |
100 |
25 |
$3K |
| D0350 |
|
262 |
112 |
$2K |
| D4910 |
|
24 |
24 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
82 |
80 |
$960.00 |