| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
629 |
629 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
522 |
520 |
$41K |
| D1120 |
Prophylaxis - child |
444 |
443 |
$21K |
| D0274 |
Bitewings - four radiographic images |
965 |
964 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,541 |
1,337 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
933 |
931 |
$13K |
| D4341 |
|
137 |
43 |
$10K |
| D1110 |
Prophylaxis - adult |
107 |
107 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
69 |
43 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
28 |
$3K |
| D9430 |
|
29 |
29 |
$928.00 |
| D0220 |
Intraoral - periapical first radiographic image |
64 |
64 |
$768.00 |