| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
998 |
995 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
721 |
719 |
$57K |
| D1120 |
Prophylaxis - child |
1,127 |
1,123 |
$55K |
| D1110 |
Prophylaxis - adult |
341 |
339 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,674 |
1,601 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,662 |
1,657 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
275 |
163 |
$18K |
| D0274 |
Bitewings - four radiographic images |
764 |
763 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
188 |
110 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
193 |
193 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
758 |
745 |
$9K |
| D1351 |
Sealant - per tooth |
226 |
46 |
$8K |
| D9430 |
|
185 |
176 |
$6K |
| D1320 |
|
77 |
77 |
$1K |
| D0350 |
|
106 |
29 |
$1K |