| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,197 |
1,193 |
$65K |
| D1120 |
Prophylaxis - child |
1,569 |
1,564 |
$60K |
| D9430 |
|
1,667 |
1,631 |
$53K |
| D0220 |
Intraoral - periapical first radiographic image |
2,768 |
2,365 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,462 |
2,603 |
$31K |
| D1206 |
Topical application of fluoride varnish |
1,766 |
1,759 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
439 |
439 |
$25K |
| D1110 |
Prophylaxis - adult |
267 |
267 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,309 |
1,304 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
185 |
108 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
103 |
68 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
581 |
581 |
$6K |
| D4910 |
|
75 |
75 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
69 |
69 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
21 |
13 |
$1K |
| D9993 |
|
13 |
13 |
$845.00 |
| D1310 |
|
13 |
13 |
$598.00 |
| D0240 |
|
24 |
12 |
$240.00 |
| D1999 |
|
187 |
171 |
$0.00 |