| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
855 |
851 |
$53K |
| D1120 |
Prophylaxis - child |
628 |
625 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,417 |
1,412 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,850 |
1,439 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
159 |
159 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
107 |
59 |
$7K |
| D0274 |
Bitewings - four radiographic images |
323 |
320 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
98 |
51 |
$5K |
| D0350 |
|
452 |
210 |
$3K |
| D4910 |
|
39 |
39 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
42 |
$2K |
| D9430 |
|
18 |
17 |
$576.00 |
| D0272 |
Bitewings - two radiographic images |
38 |
38 |
$402.00 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
16 |
$150.00 |
| D0270 |
|
12 |
12 |
$60.00 |