| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,422 |
1,418 |
$81K |
| D1110 |
Prophylaxis - adult |
616 |
616 |
$51K |
| D1120 |
Prophylaxis - child |
1,293 |
1,291 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
617 |
617 |
$39K |
| D1206 |
Topical application of fluoride varnish |
1,972 |
1,963 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
318 |
191 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,925 |
1,108 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
221 |
221 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
164 |
93 |
$9K |
| D0272 |
Bitewings - two radiographic images |
681 |
681 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
455 |
454 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
178 |
173 |
$2K |
| D9430 |
|
31 |
30 |
$992.00 |