| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,219 |
2,197 |
$126K |
| D1120 |
Prophylaxis - child |
2,223 |
2,196 |
$86K |
| D0230 |
Intraoral - periapical each additional radiographic image |
15,118 |
2,912 |
$63K |
| D0272 |
Bitewings - two radiographic images |
2,499 |
2,474 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,202 |
2,176 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
66 |
66 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
13 |
$1K |
| D9430 |
|
24 |
24 |
$768.00 |