| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,562 |
1,525 |
$66K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,663 |
1,622 |
$42K |
| D1120 |
Prophylaxis - child |
1,157 |
1,119 |
$39K |
| D1110 |
Prophylaxis - adult |
134 |
134 |
$13K |
| D9999 |
Unspecified adjunctive procedure, by report |
67 |
67 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$2K |
| D1320 |
|
229 |
229 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
370 |
350 |
$2K |
| D0274 |
Bitewings - four radiographic images |
69 |
69 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
881 |
320 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
24 |
$1K |
| D1206 |
Topical application of fluoride varnish |
31 |
31 |
$997.00 |
| D0350 |
|
471 |
166 |
$988.80 |
| D0272 |
Bitewings - two radiographic images |
163 |
159 |
$704.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$451.80 |
| D1999 |
|
126 |
112 |
$400.00 |
| D0601 |
|
368 |
365 |
$152.00 |