| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
447 |
426 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
682 |
664 |
$18K |
| D1120 |
Prophylaxis - child |
367 |
362 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
419 |
400 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
150 |
133 |
$6K |
| D0272 |
Bitewings - two radiographic images |
316 |
299 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
15 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
174 |
164 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
99 |
82 |
$776.86 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$730.26 |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$291.48 |