| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
612 |
611 |
$24K |
| D1120 |
Prophylaxis - child |
784 |
781 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,082 |
997 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,146 |
1,078 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
200 |
128 |
$13K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
139 |
78 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
135 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
812 |
809 |
$8K |
| D1351 |
Sealant - per tooth |
340 |
112 |
$7K |
| D1110 |
Prophylaxis - adult |
79 |
78 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
38 |
$3K |
| D2160 |
|
32 |
25 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$1K |
| D0350 |
|
54 |
40 |
$495.60 |