| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
426 |
421 |
$28K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
149 |
58 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
674 |
659 |
$21K |
| D1206 |
Topical application of fluoride varnish |
673 |
659 |
$17K |
| D1120 |
Prophylaxis - child |
73 |
71 |
$3K |
| D0272 |
Bitewings - two radiographic images |
157 |
155 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
18 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
84 |
84 |
$992.88 |
| D1330 |
|
84 |
82 |
$538.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
38 |
38 |
$249.28 |