| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,114 |
3,100 |
$165K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
2,211 |
867 |
$118K |
| D1120 |
Prophylaxis - child |
2,914 |
2,900 |
$103K |
| D0230 |
Intraoral - periapical each additional radiographic image |
20,381 |
4,015 |
$82K |
| D1110 |
Prophylaxis - adult |
684 |
683 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
821 |
488 |
$55K |
| D0274 |
Bitewings - four radiographic images |
2,396 |
2,382 |
$51K |
| D0350 |
|
4,444 |
1,110 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
649 |
648 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,220 |
3,204 |
$35K |
| D0210 |
Intraoral - complete series of radiographic images |
461 |
459 |
$21K |
| D1351 |
Sealant - per tooth |
757 |
183 |
$20K |
| D9430 |
|
562 |
542 |
$18K |
| D1206 |
Topical application of fluoride varnish |
547 |
547 |
$9K |
| D4910 |
|
93 |
93 |
$7K |
| D0272 |
Bitewings - two radiographic images |
356 |
355 |
$4K |
| D0330 |
Panoramic radiographic image |
80 |
78 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
182 |
173 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
23 |
14 |
$2K |
| D0340 |
|
15 |
13 |
$750.00 |
| D0270 |
|
103 |
102 |
$507.50 |