| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,071 |
1,063 |
$57K |
| D1120 |
Prophylaxis - child |
1,416 |
1,409 |
$53K |
| D0274 |
Bitewings - four radiographic images |
1,103 |
1,095 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,681 |
1,668 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
284 |
279 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,429 |
1,297 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
126 |
123 |
$5K |
| D1351 |
Sealant - per tooth |
165 |
44 |
$4K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
17 |
$2K |
| D9430 |
|
15 |
15 |
$420.00 |