| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,740 |
1,735 |
$109K |
| D1110 |
Prophylaxis - adult |
913 |
912 |
$81K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,650 |
1,862 |
$49K |
| D1120 |
Prophylaxis - child |
1,185 |
1,179 |
$48K |
| D4910 |
|
453 |
447 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,485 |
2,471 |
$31K |
| D9430 |
|
936 |
839 |
$30K |
| D0274 |
Bitewings - four radiographic images |
1,352 |
1,349 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
378 |
376 |
$23K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
113 |
63 |
$8K |
| D0350 |
|
498 |
259 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
87 |
86 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
13 |
$3K |
| D1351 |
Sealant - per tooth |
71 |
25 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |