| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
276 |
276 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
196 |
196 |
$12K |
| D1110 |
Prophylaxis - adult |
129 |
128 |
$11K |
| D1206 |
Topical application of fluoride varnish |
217 |
217 |
$3K |
| D1120 |
Prophylaxis - child |
40 |
40 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
350 |
165 |
$1K |
| D0274 |
Bitewings - four radiographic images |
63 |
63 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
45 |
45 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$1K |