| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,872 |
1,828 |
$27K |
| D1120 |
Prophylaxis - child |
1,006 |
989 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
2,160 |
2,052 |
$8K |
| D1110 |
Prophylaxis - adult |
447 |
441 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
395 |
391 |
$6K |
| D0274 |
Bitewings - four radiographic images |
895 |
874 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,129 |
1,106 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,058 |
1,436 |
$4K |
| D9430 |
|
83 |
82 |
$792.00 |
| D1206 |
Topical application of fluoride varnish |
30 |
30 |
$524.00 |
| D0210 |
Intraoral - complete series of radiographic images |
244 |
239 |
$504.00 |
| D1330 |
|
968 |
923 |
$0.00 |
| D1351 |
Sealant - per tooth |
17 |
14 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
14 |
$0.00 |