| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,188 |
1,171 |
$32K |
| D1120 |
Prophylaxis - child |
687 |
684 |
$23K |
| D1110 |
Prophylaxis - adult |
429 |
423 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,140 |
1,128 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,212 |
573 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
126 |
74 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
634 |
624 |
$7K |
| D0274 |
Bitewings - four radiographic images |
134 |
132 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$494.48 |
| D0603 |
|
1,172 |
1,154 |
$0.00 |
| D0602 |
|
139 |
137 |
$0.00 |