| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,364 |
1,356 |
$84K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
919 |
517 |
$60K |
| D1120 |
Prophylaxis - child |
1,130 |
1,122 |
$42K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,676 |
1,768 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
576 |
576 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
378 |
220 |
$20K |
| D0274 |
Bitewings - four radiographic images |
903 |
895 |
$18K |
| D1110 |
Prophylaxis - adult |
199 |
199 |
$17K |
| D1206 |
Topical application of fluoride varnish |
936 |
932 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
228 |
228 |
$11K |
| D4910 |
|
126 |
126 |
$9K |
| D9430 |
|
135 |
130 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
178 |
173 |
$2K |
| D1351 |
Sealant - per tooth |
87 |
26 |
$2K |
| D0272 |
Bitewings - two radiographic images |
31 |
31 |
$372.00 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$360.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |
| D0350 |
|
73 |
20 |
$0.00 |
| D1999 |
|
18 |
18 |
$0.00 |