| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,004 |
2,000 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
1,429 |
1,426 |
$75K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,717 |
2,337 |
$60K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,090 |
3,084 |
$40K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
584 |
311 |
$39K |
| D1110 |
Prophylaxis - adult |
320 |
319 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
378 |
376 |
$23K |
| D0274 |
Bitewings - four radiographic images |
800 |
799 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
304 |
302 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
45 |
$4K |
| D0350 |
|
459 |
207 |
$4K |
| D9430 |
|
89 |
82 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
246 |
245 |
$3K |
| D4910 |
|
25 |
25 |
$2K |
| D1351 |
Sealant - per tooth |
34 |
13 |
$748.00 |