| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,096 |
2,093 |
$125K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,369 |
716 |
$91K |
| D1120 |
Prophylaxis - child |
2,126 |
2,123 |
$84K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,410 |
2,366 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
654 |
653 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,768 |
1,765 |
$38K |
| D0350 |
|
3,179 |
1,273 |
$32K |
| D1206 |
Topical application of fluoride varnish |
2,475 |
2,472 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
374 |
374 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
312 |
209 |
$17K |
| D1110 |
Prophylaxis - adult |
134 |
134 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
108 |
66 |
$9K |
| D9430 |
|
180 |
166 |
$6K |
| D1351 |
Sealant - per tooth |
38 |
13 |
$792.00 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$192.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$144.00 |