| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,205 |
1,204 |
$106K |
| D0120 |
Periodic oral evaluation - established patient |
1,121 |
1,120 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
953 |
952 |
$61K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,335 |
2,333 |
$31K |
| D1120 |
Prophylaxis - child |
694 |
692 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
539 |
539 |
$25K |
| D0274 |
Bitewings - four radiographic images |
967 |
967 |
$19K |
| D2332 |
|
218 |
53 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,157 |
1,234 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
213 |
63 |
$11K |
| D0350 |
|
1,153 |
264 |
$9K |
| D9430 |
|
224 |
220 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
141 |
140 |
$2K |
| D1330 |
|
51 |
51 |
$0.00 |