| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
795 |
790 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,044 |
1,319 |
$22K |
| D1120 |
Prophylaxis - child |
713 |
713 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
337 |
337 |
$20K |
| D0274 |
Bitewings - four radiographic images |
524 |
524 |
$11K |
| D9430 |
|
257 |
224 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
839 |
838 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
104 |
104 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
50 |
29 |
$3K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
28 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
208 |
200 |
$2K |