| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,578 |
1,576 |
$84K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,378 |
2,523 |
$53K |
| D1120 |
Prophylaxis - child |
1,409 |
1,406 |
$51K |
| D1206 |
Topical application of fluoride varnish |
1,895 |
1,893 |
$25K |
| D1110 |
Prophylaxis - adult |
227 |
227 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,590 |
1,585 |
$19K |
| D0274 |
Bitewings - four radiographic images |
323 |
323 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
70 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
277 |
264 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
32 |
24 |
$3K |