| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,140 |
1,128 |
$70K |
| D1110 |
Prophylaxis - adult |
452 |
448 |
$40K |
| D1120 |
Prophylaxis - child |
843 |
834 |
$34K |
| D1206 |
Topical application of fluoride varnish |
2,014 |
1,997 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
277 |
277 |
$18K |
| D0274 |
Bitewings - four radiographic images |
613 |
603 |
$13K |
| D4910 |
|
139 |
139 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
126 |
126 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
43 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
27 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
560 |
164 |
$2K |
| D9430 |
|
13 |
12 |
$416.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$180.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$168.00 |