| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,971 |
1,968 |
$108K |
| D1120 |
Prophylaxis - child |
1,666 |
1,664 |
$59K |
| D1110 |
Prophylaxis - adult |
538 |
537 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
606 |
606 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,889 |
2,885 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,950 |
1,995 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
419 |
419 |
$20K |
| D9430 |
|
603 |
594 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,312 |
1,277 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
214 |
111 |
$12K |
| D0274 |
Bitewings - four radiographic images |
410 |
408 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
37 |
$3K |
| D4341 |
|
46 |
13 |
$3K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |