| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,507 |
1,482 |
$101K |
| D1110 |
Prophylaxis - adult |
808 |
789 |
$70K |
| D1120 |
Prophylaxis - child |
1,244 |
1,234 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
606 |
604 |
$38K |
| D1206 |
Topical application of fluoride varnish |
1,994 |
1,963 |
$29K |
| D0274 |
Bitewings - four radiographic images |
1,327 |
1,304 |
$27K |
| D0210 |
Intraoral - complete series of radiographic images |
324 |
323 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,387 |
1,204 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
67 |
37 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
306 |
304 |
$3K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$144.00 |
| D1999 |
|
155 |
152 |
$18.75 |