| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
791 |
787 |
$30K |
| D1120 |
Prophylaxis - child |
781 |
776 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,858 |
1,063 |
$23K |
| D1110 |
Prophylaxis - adult |
249 |
249 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
241 |
241 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,079 |
1,074 |
$10K |
| D0274 |
Bitewings - four radiographic images |
501 |
498 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
68 |
39 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
65 |
29 |
$4K |
| D1351 |
Sealant - per tooth |
169 |
48 |
$4K |
| D0272 |
Bitewings - two radiographic images |
314 |
312 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
180 |
174 |
$2K |
| D9430 |
|
28 |
26 |
$812.00 |
| D0350 |
|
83 |
29 |
$787.20 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$624.00 |