| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,379 |
1,361 |
$78K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,963 |
1,819 |
$36K |
| D1120 |
Prophylaxis - child |
807 |
802 |
$30K |
| D1110 |
Prophylaxis - adult |
343 |
336 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,860 |
1,840 |
$23K |
| D0274 |
Bitewings - four radiographic images |
1,074 |
1,056 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
302 |
301 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
290 |
168 |
$19K |
| D0210 |
Intraoral - complete series of radiographic images |
170 |
170 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
47 |
26 |
$3K |
| D4910 |
|
27 |
27 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
24 |
12 |
$2K |
| D0350 |
|
191 |
93 |
$2K |
| D1351 |
Sealant - per tooth |
34 |
12 |
$1K |
| D9430 |
|
12 |
12 |
$384.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |
| D1999 |
|
140 |
129 |
$0.00 |