| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,291 |
1,285 |
$53K |
| D9110 |
|
711 |
682 |
$44K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,607 |
1,686 |
$35K |
| D1120 |
Prophylaxis - child |
1,093 |
1,089 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,022 |
1,020 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,232 |
1,228 |
$11K |
| D9430 |
|
201 |
183 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
68 |
$4K |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$3K |
| D1351 |
Sealant - per tooth |
85 |
13 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$940.80 |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
54 |
$633.00 |
| D0272 |
Bitewings - two radiographic images |
29 |
29 |
$336.00 |