| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,167 |
1,162 |
$15K |
| D1110 |
Prophylaxis - adult |
1,212 |
1,208 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
187 |
99 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
332 |
332 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
889 |
883 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
632 |
627 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
97 |
97 |
$2K |
| D0274 |
Bitewings - four radiographic images |
221 |
220 |
$2K |
| D1120 |
Prophylaxis - child |
114 |
114 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
114 |
114 |
$693.00 |
| D1206 |
Topical application of fluoride varnish |
17 |
17 |
$210.00 |