| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
756 |
748 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
394 |
393 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
353 |
199 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,478 |
1,060 |
$22K |
| D0350 |
|
1,607 |
641 |
$16K |
| D1206 |
Topical application of fluoride varnish |
1,081 |
1,077 |
$14K |
| D1110 |
Prophylaxis - adult |
161 |
161 |
$13K |
| D4341 |
|
162 |
49 |
$11K |
| D1120 |
Prophylaxis - child |
332 |
330 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
235 |
230 |
$11K |
| D0272 |
Bitewings - two radiographic images |
632 |
626 |
$7K |
| D9430 |
|
76 |
72 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
26 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
24 |
$312.00 |