| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
273 |
268 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
167 |
156 |
$11K |
| D1120 |
Prophylaxis - child |
256 |
246 |
$4K |
| D1110 |
Prophylaxis - adult |
162 |
151 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
60 |
33 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
12 |
$753.86 |
| D1208 |
Topical application of fluoride, excluding varnish |
464 |
444 |
$429.39 |
| D1330 |
|
516 |
493 |
$317.83 |
| D0272 |
Bitewings - two radiographic images |
220 |
214 |
$200.85 |
| D0220 |
Intraoral - periapical first radiographic image |
546 |
521 |
$144.45 |
| D0274 |
Bitewings - four radiographic images |
171 |
159 |
$95.15 |
| D0230 |
Intraoral - periapical each additional radiographic image |
475 |
452 |
$4.48 |