| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
268 |
268 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,392 |
659 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
721 |
664 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
145 |
139 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
75 |
39 |
$4K |
| D4910 |
|
53 |
53 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
76 |
75 |
$2K |
| D0272 |
Bitewings - two radiographic images |
112 |
112 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
88 |
88 |
$1K |