| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
497 |
497 |
$21K |
| D1120 |
Prophylaxis - child |
384 |
383 |
$11K |
| D1110 |
Prophylaxis - adult |
145 |
144 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
192 |
192 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
939 |
937 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
806 |
788 |
$9K |
| D9430 |
|
295 |
260 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
68 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
174 |
173 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
766 |
678 |
$7K |
| D0350 |
|
283 |
247 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$574.80 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$120.00 |