| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
742 |
742 |
$24K |
| D1120 |
Prophylaxis - child |
775 |
773 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,681 |
848 |
$17K |
| D0274 |
Bitewings - four radiographic images |
568 |
566 |
$11K |
| D1351 |
Sealant - per tooth |
470 |
164 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
138 |
91 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
188 |
186 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
109 |
56 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
811 |
809 |
$6K |
| D9430 |
|
184 |
184 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
76 |
48 |
$4K |
| D0350 |
|
382 |
234 |
$3K |
| D0272 |
Bitewings - two radiographic images |
230 |
230 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
190 |
190 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D2140 |
|
14 |
12 |
$764.40 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$576.00 |