| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
928 |
928 |
$67K |
| D1110 |
Prophylaxis - adult |
529 |
528 |
$47K |
| D1120 |
Prophylaxis - child |
713 |
713 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,726 |
1,243 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
360 |
360 |
$23K |
| D1206 |
Topical application of fluoride varnish |
555 |
555 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
573 |
573 |
$8K |
| D0274 |
Bitewings - four radiographic images |
276 |
276 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
24 |
$4K |
| D0272 |
Bitewings - two radiographic images |
302 |
302 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
71 |
71 |
$3K |
| D0350 |
|
252 |
89 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$144.00 |