| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
564 |
564 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
755 |
755 |
$19K |
| D1120 |
Prophylaxis - child |
351 |
351 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
273 |
273 |
$11K |
| D9920 |
|
130 |
115 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
448 |
448 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
595 |
590 |
$6K |
| D0272 |
Bitewings - two radiographic images |
535 |
535 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
666 |
663 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
102 |
102 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$2K |
| D0603 |
|
45 |
45 |
$440.00 |
| D0602 |
|
37 |
37 |
$360.00 |
| D1330 |
|
977 |
975 |
$0.00 |