| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
905 |
901 |
$56K |
| D1110 |
Prophylaxis - adult |
621 |
618 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
342 |
340 |
$22K |
| D1120 |
Prophylaxis - child |
531 |
529 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,429 |
1,426 |
$18K |
| D0274 |
Bitewings - four radiographic images |
623 |
620 |
$13K |
| D4910 |
|
132 |
132 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
212 |
212 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,022 |
1,024 |
$8K |
| D4341 |
|
101 |
26 |
$7K |
| D0350 |
|
761 |
231 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
69 |
26 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
26 |
$3K |
| D1206 |
Topical application of fluoride varnish |
53 |
53 |
$926.00 |
| D9430 |
|
25 |
25 |
$800.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |
| D1999 |
|
27 |
26 |
$0.00 |