| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
933 |
930 |
$21K |
| D1110 |
Prophylaxis - adult |
467 |
467 |
$21K |
| D0274 |
Bitewings - four radiographic images |
642 |
642 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
836 |
836 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
808 |
805 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
572 |
570 |
$7K |
| D1120 |
Prophylaxis - child |
146 |
146 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$405.14 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$278.46 |