| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,685 |
1,520 |
$28K |
| D1120 |
Prophylaxis - child |
962 |
878 |
$24K |
| D1110 |
Prophylaxis - adult |
726 |
642 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,335 |
1,200 |
$16K |
| D1999 |
|
793 |
554 |
$9K |
| D1206 |
Topical application of fluoride varnish |
302 |
289 |
$7K |
| D0272 |
Bitewings - two radiographic images |
299 |
262 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
123 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
14 |
$1K |
| D0274 |
Bitewings - four radiographic images |
48 |
44 |
$976.80 |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
58 |
$623.70 |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
12 |
$199.50 |