| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,200 |
1,199 |
$87K |
| D1110 |
Prophylaxis - adult |
813 |
813 |
$73K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
906 |
906 |
$60K |
| D1120 |
Prophylaxis - child |
1,165 |
1,164 |
$54K |
| D0350 |
|
5,564 |
1,827 |
$52K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
479 |
281 |
$32K |
| D0210 |
Intraoral - complete series of radiographic images |
651 |
651 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,715 |
1,589 |
$23K |
| D0274 |
Bitewings - four radiographic images |
1,066 |
1,065 |
$21K |
| D0330 |
Panoramic radiographic image |
682 |
682 |
$20K |
| D1206 |
Topical application of fluoride varnish |
958 |
958 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,020 |
1,017 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
58 |
39 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
14 |
$2K |
| D4910 |
|
12 |
12 |
$924.00 |
| D1351 |
Sealant - per tooth |
29 |
12 |
$638.00 |
| D0220 |
Intraoral - periapical first radiographic image |
36 |
36 |
$420.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$156.00 |
| D1999 |
|
12 |
12 |
$0.00 |