| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,996 |
1,991 |
$109K |
| D1120 |
Prophylaxis - child |
1,977 |
1,974 |
$74K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
766 |
764 |
$46K |
| D1110 |
Prophylaxis - adult |
425 |
422 |
$34K |
| D0210 |
Intraoral - complete series of radiographic images |
473 |
472 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,331 |
1,045 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
951 |
898 |
$11K |
| D0274 |
Bitewings - four radiographic images |
535 |
532 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
99 |
73 |
$6K |
| D9430 |
|
59 |
58 |
$2K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$420.00 |