| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,326 |
1,325 |
$74K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,117 |
2,403 |
$54K |
| D1120 |
Prophylaxis - child |
1,266 |
1,265 |
$48K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
767 |
766 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,859 |
1,858 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,839 |
1,837 |
$26K |
| D4341 |
|
218 |
72 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
172 |
80 |
$13K |
| D1110 |
Prophylaxis - adult |
57 |
57 |
$5K |
| D1351 |
Sealant - per tooth |
56 |
12 |
$1K |
| D0350 |
|
47 |
42 |
$457.20 |
| D0272 |
Bitewings - two radiographic images |
40 |
40 |
$440.00 |