| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,813 |
1,791 |
$113K |
| D1120 |
Prophylaxis - child |
1,595 |
1,578 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
804 |
417 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
624 |
621 |
$37K |
| D1110 |
Prophylaxis - adult |
343 |
343 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,843 |
2,282 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,796 |
1,775 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
389 |
386 |
$17K |
| D1206 |
Topical application of fluoride varnish |
864 |
861 |
$11K |
| D9430 |
|
296 |
278 |
$9K |
| D4910 |
|
94 |
94 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
461 |
454 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
29 |
$4K |
| D9993 |
|
53 |
53 |
$3K |
| D1310 |
|
53 |
53 |
$2K |
| D4341 |
|
33 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
26 |
$1K |
| D1351 |
Sealant - per tooth |
38 |
12 |
$836.00 |
| D0220 |
Intraoral - periapical first radiographic image |
41 |
41 |
$492.00 |
| D0350 |
|
85 |
82 |
$399.60 |