| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
499 |
498 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
379 |
375 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,196 |
961 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
188 |
80 |
$13K |
| D1120 |
Prophylaxis - child |
292 |
285 |
$10K |
| D1110 |
Prophylaxis - adult |
104 |
104 |
$9K |
| D0274 |
Bitewings - four radiographic images |
441 |
440 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
103 |
33 |
$8K |
| D1206 |
Topical application of fluoride varnish |
432 |
428 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
114 |
42 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
505 |
503 |
$5K |
| D1351 |
Sealant - per tooth |
148 |
29 |
$3K |
| D9430 |
|
92 |
87 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
37 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$168.00 |