| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,995 |
1,991 |
$46K |
| D1120 |
Prophylaxis - child |
996 |
996 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,684 |
1,680 |
$19K |
| D1110 |
Prophylaxis - adult |
720 |
720 |
$16K |
| D0274 |
Bitewings - four radiographic images |
996 |
996 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,788 |
1,307 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,502 |
1,480 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
25 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
14 |
$951.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$322.00 |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$217.35 |