| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
577 |
574 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,968 |
713 |
$13K |
| D1120 |
Prophylaxis - child |
390 |
387 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
142 |
70 |
$9K |
| D0350 |
|
767 |
340 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
655 |
650 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
109 |
52 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
94 |
$5K |
| D0274 |
Bitewings - four radiographic images |
231 |
229 |
$5K |
| D4341 |
|
42 |
12 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
58 |
$3K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$2K |
| D1999 |
|
389 |
360 |
$92.00 |