| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,164 |
1,136 |
$74K |
| D1120 |
Prophylaxis - child |
1,219 |
1,208 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
772 |
769 |
$53K |
| D1110 |
Prophylaxis - adult |
369 |
357 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
489 |
477 |
$23K |
| D0274 |
Bitewings - four radiographic images |
961 |
953 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,034 |
1,025 |
$14K |
| D1351 |
Sealant - per tooth |
357 |
79 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,008 |
1,622 |
$12K |
| D0350 |
|
774 |
260 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
38 |
$4K |
| D9430 |
|
94 |
93 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
153 |
151 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
14 |
$2K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
14 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
91 |
91 |
$1K |