| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
680 |
570 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
831 |
741 |
$11K |
| D1110 |
Prophylaxis - adult |
243 |
211 |
$8K |
| D1120 |
Prophylaxis - child |
317 |
281 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
83 |
73 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
181 |
149 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
55 |
50 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
57 |
51 |
$525.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$207.90 |