| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,647 |
1,613 |
$73K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,684 |
1,665 |
$26K |
| D1120 |
Prophylaxis - child |
606 |
593 |
$18K |
| D1110 |
Prophylaxis - adult |
160 |
160 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
961 |
884 |
$8K |
| D0272 |
Bitewings - two radiographic images |
1,000 |
973 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
90 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
55 |
24 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
906 |
456 |
$3K |
| D4341 |
|
47 |
13 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$2K |
| D4910 |
|
13 |
13 |
$781.00 |
| D1999 |
|
99 |
88 |
$260.00 |