| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
675 |
670 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
643 |
640 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
538 |
537 |
$15K |
| D4341 |
|
24 |
15 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
722 |
700 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
665 |
649 |
$3K |
| D8670 |
Periodic orthodontic treatment visit |
12 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
133 |
128 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
67 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
26 |
$1K |
| D1110 |
Prophylaxis - adult |
20 |
19 |
$697.00 |
| D0210 |
Intraoral - complete series of radiographic images |
21 |
17 |
$491.10 |