| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
444 |
424 |
$3K |
| D1120 |
Prophylaxis - child |
307 |
299 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
252 |
242 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
174 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
121 |
116 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
61 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
68 |
42 |
$914.30 |
| D1110 |
Prophylaxis - adult |
96 |
94 |
$861.00 |
| D0220 |
Intraoral - periapical first radiographic image |
456 |
440 |
$552.00 |
| D0272 |
Bitewings - two radiographic images |
319 |
311 |
$386.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
873 |
412 |
$385.80 |
| D0274 |
Bitewings - four radiographic images |
101 |
96 |
$198.00 |
| D9430 |
|
12 |
12 |
$0.00 |