| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
346 |
346 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
202 |
202 |
$13K |
| D1110 |
Prophylaxis - adult |
130 |
130 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
818 |
817 |
$10K |
| D1120 |
Prophylaxis - child |
148 |
148 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
39 |
$2K |
| D0274 |
Bitewings - four radiographic images |
68 |
67 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
344 |
161 |
$1K |