| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
927 |
917 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,332 |
1,315 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
1,108 |
1,101 |
$26K |
| D1120 |
Prophylaxis - child |
374 |
372 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
149 |
145 |
$8K |
| D0274 |
Bitewings - four radiographic images |
247 |
246 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
543 |
534 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
652 |
336 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
112 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
29 |
$3K |
| D1206 |
Topical application of fluoride varnish |
18 |
18 |
$405.90 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$240.89 |