| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
967 |
962 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
718 |
716 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
664 |
662 |
$43K |
| D0210 |
Intraoral - complete series of radiographic images |
409 |
407 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,389 |
1,385 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,865 |
1,153 |
$16K |
| D0274 |
Bitewings - four radiographic images |
708 |
706 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
216 |
76 |
$12K |
| D1120 |
Prophylaxis - child |
166 |
166 |
$7K |
| D1206 |
Topical application of fluoride varnish |
277 |
277 |
$4K |
| D0350 |
|
301 |
111 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
12 |
$2K |
| D9430 |
|
40 |
40 |
$1K |