| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
508 |
508 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,883 |
1,232 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
459 |
459 |
$27K |
| D0274 |
Bitewings - four radiographic images |
998 |
993 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
383 |
200 |
$21K |
| D1120 |
Prophylaxis - child |
233 |
228 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
102 |
69 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
73 |
73 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
188 |
188 |
$2K |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$1K |