| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,257 |
2,251 |
$129K |
| D1110 |
Prophylaxis - adult |
1,134 |
1,127 |
$88K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
921 |
917 |
$59K |
| D1120 |
Prophylaxis - child |
1,270 |
1,267 |
$49K |
| D1206 |
Topical application of fluoride varnish |
2,086 |
2,077 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,006 |
1,003 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,960 |
1,669 |
$11K |
| D9430 |
|
372 |
348 |
$11K |
| D9999 |
Unspecified adjunctive procedure, by report |
83 |
81 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
282 |
282 |
$11K |
| D1351 |
Sealant - per tooth |
191 |
38 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
54 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
646 |
637 |
$4K |
| D4910 |
|
51 |
51 |
$3K |
| D0330 |
Panoramic radiographic image |
48 |
48 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
13 |
$1K |
| D0999 |
Unspecified diagnostic procedure, by report |
15 |
15 |
$900.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$203.00 |
| D1999 |
|
126 |
116 |
$200.00 |