| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,016 |
1,011 |
$55K |
| D1110 |
Prophylaxis - adult |
382 |
382 |
$33K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,285 |
1,277 |
$16K |
| D1120 |
Prophylaxis - child |
315 |
311 |
$10K |
| D0350 |
|
673 |
346 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
132 |
70 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
99 |
63 |
$7K |
| D9430 |
|
164 |
160 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
72 |
$4K |
| D0274 |
Bitewings - four radiographic images |
156 |
155 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
57 |
$3K |
| D1206 |
Topical application of fluoride varnish |
98 |
98 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
168 |
75 |
$674.33 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$120.00 |