| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
772 |
769 |
$42K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,757 |
1,676 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
450 |
189 |
$24K |
| D0274 |
Bitewings - four radiographic images |
1,036 |
1,031 |
$21K |
| D1110 |
Prophylaxis - adult |
205 |
204 |
$18K |
| D1120 |
Prophylaxis - child |
419 |
416 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,128 |
1,121 |
$13K |
| D0350 |
|
518 |
154 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
51 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
13 |
$2K |