| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
837 |
836 |
$64K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,450 |
1,386 |
$32K |
| D1120 |
Prophylaxis - child |
615 |
615 |
$32K |
| D1110 |
Prophylaxis - adult |
316 |
316 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
254 |
254 |
$17K |
| D0272 |
Bitewings - two radiographic images |
926 |
925 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
551 |
551 |
$8K |
| D4341 |
|
86 |
25 |
$6K |
| D0274 |
Bitewings - four radiographic images |
216 |
216 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
12 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
21 |
12 |
$1K |