| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,756 |
1,741 |
$99K |
| D1110 |
Prophylaxis - adult |
520 |
518 |
$45K |
| D1120 |
Prophylaxis - child |
984 |
971 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,666 |
1,648 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
471 |
469 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,899 |
1,922 |
$19K |
| D1206 |
Topical application of fluoride varnish |
642 |
634 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
927 |
913 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
134 |
132 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$1K |
| D4910 |
|
12 |
12 |
$924.00 |
| D0350 |
|
24 |
13 |
$211.20 |