| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
906 |
897 |
$29K |
| D0274 |
Bitewings - four radiographic images |
700 |
695 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
840 |
827 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
257 |
133 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
295 |
126 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
914 |
892 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
730 |
722 |
$6K |
| D1206 |
Topical application of fluoride varnish |
203 |
201 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
160 |
158 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
57 |
$2K |
| D1310 |
|
181 |
180 |
$1K |
| D1330 |
|
166 |
165 |
$1K |
| D1120 |
Prophylaxis - child |
41 |
40 |
$933.43 |
| D9110 |
|
31 |
28 |
$867.00 |
| D0601 |
|
80 |
79 |
$610.00 |