| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,143 |
1,131 |
$59K |
| D9430 |
|
1,842 |
1,634 |
$58K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,919 |
2,307 |
$35K |
| D1120 |
Prophylaxis - child |
722 |
714 |
$24K |
| D0274 |
Bitewings - four radiographic images |
673 |
664 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,163 |
1,081 |
$14K |
| D1110 |
Prophylaxis - adult |
123 |
123 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
806 |
797 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
97 |
94 |
$5K |
| D1320 |
|
288 |
283 |
$3K |
| D1206 |
Topical application of fluoride varnish |
183 |
183 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$576.00 |
| D0350 |
|
60 |
38 |
$505.20 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$288.00 |
| D0180 |
|
40 |
40 |
$0.00 |