| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,594 |
1,594 |
$28K |
| D1120 |
Prophylaxis - child |
1,275 |
1,275 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
532 |
272 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,634 |
1,602 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,963 |
1,899 |
$9K |
| D1110 |
Prophylaxis - adult |
478 |
478 |
$8K |
| D1206 |
Topical application of fluoride varnish |
1,011 |
1,011 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
206 |
119 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
247 |
247 |
$4K |
| D0274 |
Bitewings - four radiographic images |
424 |
424 |
$3K |
| D0272 |
Bitewings - two radiographic images |
621 |
621 |
$3K |
| D1351 |
Sealant - per tooth |
422 |
62 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
42 |
$670.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
24 |
$540.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
182 |
182 |
$252.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$84.00 |