| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
296 |
296 |
$23K |
| D1110 |
Prophylaxis - adult |
244 |
243 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
177 |
176 |
$12K |
| D1120 |
Prophylaxis - child |
195 |
195 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,993 |
725 |
$8K |
| D0274 |
Bitewings - four radiographic images |
321 |
321 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
175 |
175 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
24 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$1K |