| Code | Description | Claims | Beneficiaries | Total Paid |
| D0150 |
Comprehensive oral evaluation - new or established patient |
659 |
656 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
610 |
601 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
447 |
447 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,320 |
949 |
$18K |
| D1120 |
Prophylaxis - child |
339 |
335 |
$13K |
| D0274 |
Bitewings - four radiographic images |
362 |
359 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
569 |
567 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
100 |
41 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
26 |
$3K |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$140.00 |
| D1999 |
|
84 |
84 |
$0.00 |