| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,209 |
1,203 |
$92K |
| D1110 |
Prophylaxis - adult |
764 |
762 |
$68K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
869 |
866 |
$57K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
761 |
412 |
$51K |
| D1120 |
Prophylaxis - child |
1,005 |
1,003 |
$46K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,016 |
1,732 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,251 |
1,250 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
479 |
268 |
$26K |
| D0210 |
Intraoral - complete series of radiographic images |
424 |
422 |
$20K |
| D4910 |
|
241 |
240 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,213 |
1,211 |
$16K |
| D1206 |
Topical application of fluoride varnish |
437 |
436 |
$8K |
| D9430 |
|
148 |
147 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$780.00 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$168.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$156.00 |