| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
873 |
871 |
$35K |
| D1120 |
Prophylaxis - child |
602 |
601 |
$18K |
| D0274 |
Bitewings - four radiographic images |
733 |
732 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,493 |
1,133 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
924 |
922 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
143 |
143 |
$9K |
| D1110 |
Prophylaxis - adult |
58 |
58 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$1K |