| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,535 |
1,505 |
$49K |
| D1120 |
Prophylaxis - child |
1,201 |
1,174 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,305 |
1,779 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
278 |
125 |
$16K |
| D0274 |
Bitewings - four radiographic images |
754 |
747 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
179 |
178 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
806 |
803 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
92 |
42 |
$6K |
| D1351 |
Sealant - per tooth |
290 |
82 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
72 |
72 |
$3K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$2K |
| D4341 |
|
41 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
422 |
407 |
$2K |
| D9430 |
|
90 |
81 |
$2K |
| D1320 |
|
90 |
90 |
$964.02 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
14 |
$874.20 |
| D4910 |
|
12 |
12 |
$824.57 |
| D0272 |
Bitewings - two radiographic images |
88 |
87 |
$786.00 |
| D0220 |
Intraoral - periapical first radiographic image |
64 |
61 |
$577.60 |
| D1330 |
|
135 |
129 |
$0.00 |
| D1999 |
|
71 |
64 |
$0.00 |