| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,611 |
2,597 |
$148K |
| D1120 |
Prophylaxis - child |
2,714 |
2,702 |
$107K |
| D0274 |
Bitewings - four radiographic images |
1,443 |
1,433 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,671 |
3,209 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,791 |
1,784 |
$21K |
| D0272 |
Bitewings - two radiographic images |
845 |
845 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
113 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
416 |
407 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
17 |
$2K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$1K |
| D0250 |
|
39 |
38 |
$858.00 |