| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
723 |
723 |
$48K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,429 |
1,424 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
940 |
934 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
326 |
325 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,420 |
1,385 |
$15K |
| D0274 |
Bitewings - four radiographic images |
493 |
491 |
$12K |
| D1120 |
Prophylaxis - child |
248 |
245 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,261 |
1,241 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
14 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
54 |
54 |
$3K |
| D1206 |
Topical application of fluoride varnish |
29 |
29 |
$762.41 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$375.00 |