| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
777 |
768 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
884 |
878 |
$58K |
| D0210 |
Intraoral - complete series of radiographic images |
742 |
737 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
214 |
211 |
$15K |
| D1206 |
Topical application of fluoride varnish |
759 |
751 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
101 |
72 |
$7K |
| D9430 |
|
129 |
127 |
$4K |
| D0274 |
Bitewings - four radiographic images |
179 |
168 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
451 |
225 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
14 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
69 |
$840.00 |
| D0350 |
|
35 |
18 |
$326.40 |