| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
853 |
850 |
$37K |
| D1110 |
Prophylaxis - adult |
236 |
235 |
$18K |
| D1120 |
Prophylaxis - child |
408 |
406 |
$13K |
| D0274 |
Bitewings - four radiographic images |
541 |
539 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,288 |
1,174 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
244 |
242 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
42 |
41 |
$2K |
| D9430 |
|
56 |
52 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
37 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
108 |
106 |
$1K |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$324.00 |