| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,047 |
1,046 |
$61K |
| D1110 |
Prophylaxis - adult |
575 |
573 |
$50K |
| D1208 |
Topical application of fluoride, excluding varnish |
903 |
900 |
$12K |
| D1120 |
Prophylaxis - child |
299 |
299 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,346 |
517 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
41 |
$6K |
| D0274 |
Bitewings - four radiographic images |
265 |
265 |
$6K |
| D1206 |
Topical application of fluoride varnish |
382 |
380 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
79 |
79 |
$5K |
| D4910 |
|
40 |
40 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
66 |
65 |
$3K |