| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
708 |
704 |
$36K |
| D1120 |
Prophylaxis - child |
476 |
473 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,620 |
712 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
223 |
222 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
792 |
785 |
$8K |
| D0210 |
Intraoral - complete series of radiographic images |
94 |
94 |
$4K |
| D9430 |
|
119 |
117 |
$4K |
| D1206 |
Topical application of fluoride varnish |
187 |
187 |
$3K |
| D0274 |
Bitewings - four radiographic images |
130 |
130 |
$3K |
| D0272 |
Bitewings - two radiographic images |
194 |
194 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
154 |
143 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$1K |
| D0350 |
|
36 |
13 |
$345.60 |