| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,007 |
2,004 |
$114K |
| D1120 |
Prophylaxis - child |
1,677 |
1,676 |
$62K |
| D1110 |
Prophylaxis - adult |
553 |
553 |
$49K |
| D0274 |
Bitewings - four radiographic images |
1,644 |
1,643 |
$34K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,620 |
2,616 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,819 |
2,507 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
416 |
416 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
174 |
174 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
109 |
66 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
346 |
340 |
$4K |
| D9430 |
|
70 |
68 |
$2K |
| D0272 |
Bitewings - two radiographic images |
58 |
58 |
$656.00 |
| D0350 |
|
31 |
26 |
$250.80 |