| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,578 |
1,578 |
$88K |
| D1110 |
Prophylaxis - adult |
1,003 |
1,002 |
$83K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
527 |
527 |
$32K |
| D1120 |
Prophylaxis - child |
882 |
882 |
$31K |
| D9430 |
|
909 |
805 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
287 |
154 |
$19K |
| D0274 |
Bitewings - four radiographic images |
834 |
834 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,688 |
1,695 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
139 |
68 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
644 |
632 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
92 |
92 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
403 |
403 |
$4K |