| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,074 |
1,074 |
$51K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
852 |
375 |
$46K |
| D1120 |
Prophylaxis - child |
913 |
912 |
$29K |
| D9110 |
|
429 |
416 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
1,291 |
1,173 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,291 |
1,290 |
$14K |
| D2330 |
|
119 |
54 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,752 |
756 |
$7K |
| D4910 |
|
86 |
86 |
$7K |
| D9430 |
|
122 |
119 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
83 |
83 |
$4K |
| D1110 |
Prophylaxis - adult |
46 |
46 |
$3K |
| D0272 |
Bitewings - two radiographic images |
220 |
219 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
15 |
$2K |
| D1351 |
Sealant - per tooth |
56 |
12 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
13 |
$1K |
| D0350 |
|
47 |
37 |
$566.40 |