| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,531 |
1,518 |
$110K |
| D1110 |
Prophylaxis - adult |
1,121 |
1,114 |
$99K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,244 |
1,242 |
$82K |
| D4910 |
|
681 |
680 |
$52K |
| D0210 |
Intraoral - complete series of radiographic images |
1,101 |
1,098 |
$52K |
| D1120 |
Prophylaxis - child |
1,092 |
1,081 |
$49K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,910 |
1,897 |
$27K |
| D9430 |
|
587 |
534 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
267 |
170 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,172 |
785 |
$13K |
| D1206 |
Topical application of fluoride varnish |
515 |
514 |
$8K |
| D0274 |
Bitewings - four radiographic images |
310 |
310 |
$6K |
| D4341 |
|
52 |
13 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
186 |
185 |
$2K |
| D0350 |
|
320 |
96 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$982.80 |