| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,325 |
1,322 |
$114K |
| D0120 |
Periodic oral evaluation - established patient |
1,556 |
1,552 |
$93K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,087 |
415 |
$58K |
| D0274 |
Bitewings - four radiographic images |
2,041 |
2,033 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,103 |
2,098 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,626 |
2,301 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
179 |
178 |
$12K |
| D9430 |
|
346 |
319 |
$11K |
| D1120 |
Prophylaxis - child |
307 |
306 |
$11K |
| D2330 |
|
74 |
38 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
54 |
$636.00 |