| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
442 |
438 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
440 |
440 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,203 |
1,159 |
$26K |
| D0274 |
Bitewings - four radiographic images |
819 |
814 |
$18K |
| D1110 |
Prophylaxis - adult |
145 |
145 |
$13K |
| D1120 |
Prophylaxis - child |
215 |
215 |
$11K |
| D4910 |
|
94 |
91 |
$7K |
| D1206 |
Topical application of fluoride varnish |
181 |
181 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
172 |
172 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
13 |
$2K |
| D0350 |
|
102 |
44 |
$1K |