| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,237 |
1,232 |
$107K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,529 |
1,524 |
$99K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,414 |
2,094 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,430 |
1,425 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,604 |
1,597 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
215 |
82 |
$12K |
| D9110 |
|
165 |
160 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
397 |
376 |
$5K |
| D2330 |
|
29 |
12 |
$2K |
| D1206 |
Topical application of fluoride varnish |
121 |
121 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
29 |
29 |
$973.50 |
| D1120 |
Prophylaxis - child |
17 |
17 |
$510.00 |