| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,811 |
1,779 |
$90K |
| D9430 |
|
1,312 |
1,117 |
$41K |
| D1120 |
Prophylaxis - child |
1,123 |
1,092 |
$36K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
375 |
247 |
$29K |
| D1110 |
Prophylaxis - adult |
353 |
352 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
273 |
265 |
$14K |
| D0274 |
Bitewings - four radiographic images |
608 |
603 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
245 |
241 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
171 |
100 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,328 |
663 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
69 |
51 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
350 |
324 |
$4K |
| D2394 |
|
48 |
37 |
$4K |
| D1206 |
Topical application of fluoride varnish |
175 |
166 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
313 |
311 |
$3K |
| D4341 |
|
36 |
12 |
$3K |
| D4910 |
|
12 |
12 |
$847.00 |
| D0350 |
|
15 |
13 |
$138.00 |