| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
244 |
233 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
479 |
384 |
$9K |
| D1120 |
Prophylaxis - child |
274 |
212 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
261 |
207 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
162 |
155 |
$3K |
| D0330 |
Panoramic radiographic image |
209 |
199 |
$2K |
| D0274 |
Bitewings - four radiographic images |
180 |
170 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
76 |
13 |
$722.25 |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$372.60 |