| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
357 |
349 |
$6K |
| D1110 |
Prophylaxis - adult |
180 |
176 |
$6K |
| D1120 |
Prophylaxis - child |
276 |
273 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
263 |
261 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
25 |
$2K |
| D0274 |
Bitewings - four radiographic images |
83 |
81 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
40 |
$940.78 |
| D0272 |
Bitewings - two radiographic images |
53 |
53 |
$556.50 |
| D0220 |
Intraoral - periapical first radiographic image |
87 |
84 |
$451.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
42 |
42 |
$220.50 |