| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,790 |
1,790 |
$103K |
| D1110 |
Prophylaxis - adult |
945 |
945 |
$80K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
963 |
962 |
$60K |
| D1120 |
Prophylaxis - child |
1,307 |
1,304 |
$51K |
| D0210 |
Intraoral - complete series of radiographic images |
992 |
992 |
$46K |
| D0274 |
Bitewings - four radiographic images |
1,551 |
1,551 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
264 |
154 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,414 |
1,711 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,155 |
1,154 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
51 |
$5K |
| D9430 |
|
147 |
145 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
155 |
153 |
$2K |
| D0350 |
|
32 |
16 |
$307.20 |