| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
138 |
138 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
356 |
355 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
807 |
299 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
57 |
$3K |
| D0274 |
Bitewings - four radiographic images |
110 |
110 |
$2K |
| D1120 |
Prophylaxis - child |
57 |
57 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$1K |