| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
654 |
649 |
$32K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,020 |
1,096 |
$24K |
| D1120 |
Prophylaxis - child |
454 |
450 |
$14K |
| D1110 |
Prophylaxis - adult |
154 |
153 |
$12K |
| D0274 |
Bitewings - four radiographic images |
550 |
540 |
$11K |
| D0350 |
|
1,235 |
278 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
186 |
50 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
840 |
834 |
$9K |
| D1351 |
Sealant - per tooth |
356 |
90 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
137 |
137 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
41 |
41 |
$2K |
| D0272 |
Bitewings - two radiographic images |
161 |
159 |
$2K |
| D9430 |
|
46 |
40 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
65 |
53 |
$768.00 |