| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
778 |
771 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
687 |
686 |
$42K |
| D0210 |
Intraoral - complete series of radiographic images |
395 |
395 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,727 |
906 |
$15K |
| D1120 |
Prophylaxis - child |
411 |
410 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
144 |
78 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
759 |
757 |
$9K |
| D0272 |
Bitewings - two radiographic images |
639 |
638 |
$7K |
| D1110 |
Prophylaxis - adult |
56 |
56 |
$5K |
| D2954 |
|
30 |
25 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
32 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$144.00 |