| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,089 |
3,089 |
$168K |
| D0230 |
Intraoral - periapical each additional radiographic image |
29,553 |
5,446 |
$123K |
| D1120 |
Prophylaxis - child |
2,614 |
2,611 |
$98K |
| D0274 |
Bitewings - four radiographic images |
3,640 |
3,639 |
$77K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,983 |
3,976 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
847 |
404 |
$45K |
| D1110 |
Prophylaxis - adult |
445 |
445 |
$39K |
| D4910 |
|
307 |
307 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
244 |
244 |
$16K |
| D1351 |
Sealant - per tooth |
492 |
145 |
$14K |
| D0350 |
|
1,241 |
676 |
$12K |
| D4341 |
|
120 |
31 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
122 |
54 |
$8K |
| D2140 |
|
105 |
56 |
$6K |
| D0272 |
Bitewings - two radiographic images |
181 |
179 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$576.00 |