| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,436 |
1,427 |
$84K |
| D1110 |
Prophylaxis - adult |
601 |
600 |
$53K |
| D1120 |
Prophylaxis - child |
996 |
987 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,274 |
1,678 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,070 |
2,057 |
$25K |
| D0274 |
Bitewings - four radiographic images |
838 |
834 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
254 |
254 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
189 |
88 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
200 |
200 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
123 |
53 |
$6K |
| D0350 |
|
515 |
247 |
$5K |
| D4910 |
|
42 |
42 |
$3K |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$492.00 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
12 |
$180.00 |