| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,392 |
1,385 |
$69K |
| D1120 |
Prophylaxis - child |
964 |
957 |
$33K |
| D1110 |
Prophylaxis - adult |
218 |
218 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,863 |
1,728 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
264 |
264 |
$13K |
| D0274 |
Bitewings - four radiographic images |
552 |
550 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
688 |
668 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
762 |
760 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
121 |
121 |
$5K |
| D9430 |
|
97 |
94 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
15 |
$2K |
| D0272 |
Bitewings - two radiographic images |
39 |
39 |
$435.00 |