| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,237 |
1,220 |
$76K |
| D1110 |
Prophylaxis - adult |
816 |
805 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
927 |
915 |
$63K |
| D0210 |
Intraoral - complete series of radiographic images |
1,111 |
1,100 |
$52K |
| D1120 |
Prophylaxis - child |
679 |
667 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,580 |
1,556 |
$23K |
| D0274 |
Bitewings - four radiographic images |
1,018 |
1,001 |
$21K |
| D9430 |
|
364 |
359 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,708 |
1,434 |
$11K |
| D1351 |
Sealant - per tooth |
367 |
62 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
112 |
55 |
$9K |
| D2394 |
|
81 |
27 |
$7K |
| D4341 |
|
83 |
25 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
190 |
190 |
$2K |
| D2335 |
|
18 |
13 |
$2K |
| D4910 |
|
15 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
53 |
53 |
$636.00 |
| D0270 |
|
66 |
66 |
$325.00 |
| D1330 |
|
117 |
115 |
$0.00 |
| D0601 |
|
105 |
104 |
$0.00 |