| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,845 |
2,839 |
$151K |
| D1110 |
Prophylaxis - adult |
1,739 |
1,737 |
$141K |
| D1120 |
Prophylaxis - child |
1,680 |
1,674 |
$59K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,409 |
3,400 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
754 |
402 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
557 |
360 |
$35K |
| D0350 |
|
3,578 |
1,458 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,419 |
1,650 |
$31K |
| D0210 |
Intraoral - complete series of radiographic images |
590 |
587 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
438 |
436 |
$24K |
| D1351 |
Sealant - per tooth |
421 |
100 |
$11K |
| D4910 |
|
111 |
111 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
606 |
596 |
$7K |
| D0274 |
Bitewings - four radiographic images |
176 |
176 |
$3K |
| D2330 |
|
23 |
15 |
$2K |
| D9430 |
|
39 |
39 |
$1K |
| D9951 |
|
15 |
12 |
$455.00 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$292.00 |