| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
863 |
862 |
$44K |
| D1110 |
Prophylaxis - adult |
424 |
422 |
$34K |
| D1120 |
Prophylaxis - child |
310 |
310 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
701 |
699 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
99 |
99 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$1K |
| D0272 |
Bitewings - two radiographic images |
83 |
83 |
$996.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
50 |
24 |
$218.70 |