| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,871 |
1,865 |
$101K |
| D1120 |
Prophylaxis - child |
1,649 |
1,642 |
$62K |
| D1110 |
Prophylaxis - adult |
378 |
378 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,496 |
1,489 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
474 |
474 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,832 |
1,825 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
311 |
163 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,908 |
2,023 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
173 |
99 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
196 |
196 |
$9K |
| D0350 |
|
660 |
302 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
107 |
107 |
$1K |
| D0272 |
Bitewings - two radiographic images |
37 |
37 |
$394.00 |