| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
1,482 |
1,280 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
331 |
290 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
163 |
155 |
$6K |
| D1206 |
Topical application of fluoride varnish |
284 |
248 |
$4K |
| D1120 |
Prophylaxis - child |
101 |
88 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
130 |
111 |
$3K |
| D9995 |
|
139 |
125 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
394 |
266 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
169 |
152 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
25 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
70 |
64 |
$2K |
| D1351 |
Sealant - per tooth |
191 |
27 |
$2K |
| D1110 |
Prophylaxis - adult |
43 |
39 |
$2K |
| D0274 |
Bitewings - four radiographic images |
53 |
49 |
$835.20 |
| D0170 |
|
27 |
25 |
$768.01 |
| D1354 |
|
309 |
50 |
$672.84 |
| D0603 |
|
69 |
68 |
$475.00 |
| D0191 |
|
14 |
14 |
$225.19 |
| D0270 |
|
18 |
15 |
$129.60 |
| D1310 |
|
209 |
184 |
$0.00 |
| D1330 |
|
273 |
243 |
$0.00 |