| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,108 |
2,106 |
$134K |
| D1120 |
Prophylaxis - child |
2,107 |
2,092 |
$90K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,221 |
1,218 |
$78K |
| D9430 |
|
2,064 |
1,757 |
$63K |
| D1110 |
Prophylaxis - adult |
603 |
602 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,913 |
2,907 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
671 |
326 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,798 |
3,003 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
565 |
564 |
$27K |
| D0350 |
|
2,506 |
960 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,169 |
1,141 |
$14K |
| D4910 |
|
176 |
175 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
173 |
106 |
$12K |
| D0274 |
Bitewings - four radiographic images |
484 |
484 |
$10K |
| D4341 |
|
89 |
26 |
$6K |
| D1351 |
Sealant - per tooth |
167 |
41 |
$5K |
| D1320 |
|
332 |
330 |
$4K |
| D0272 |
Bitewings - two radiographic images |
294 |
294 |
$4K |
| D1310 |
|
13 |
13 |
$506.00 |
| D0603 |
|
12 |
12 |
$165.00 |
| D9993 |
|
13 |
13 |
$0.00 |
| D1999 |
|
16 |
14 |
$0.00 |