| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,583 |
1,580 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
2,630 |
2,621 |
$51K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,739 |
1,738 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,722 |
1,722 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,729 |
1,729 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
494 |
493 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
184 |
41 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
567 |
563 |
$6K |
| D1120 |
Prophylaxis - child |
199 |
199 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
24 |
$3K |
| D1206 |
Topical application of fluoride varnish |
30 |
30 |
$717.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$437.50 |