| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,323 |
2,320 |
$133K |
| D1120 |
Prophylaxis - child |
1,945 |
1,944 |
$74K |
| D1110 |
Prophylaxis - adult |
762 |
762 |
$64K |
| D1206 |
Topical application of fluoride varnish |
2,815 |
2,813 |
$40K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,624 |
1,796 |
$23K |
| D0274 |
Bitewings - four radiographic images |
688 |
688 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
241 |
240 |
$13K |
| D1320 |
|
787 |
787 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
160 |
160 |
$7K |
| D4910 |
|
93 |
93 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
86 |
56 |
$6K |
| D1351 |
Sealant - per tooth |
112 |
26 |
$3K |
| D9430 |
|
100 |
94 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
148 |
148 |
$1K |
| D0350 |
|
176 |
70 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$873.60 |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$480.00 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$312.00 |