| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,274 |
1,273 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
1,224 |
1,223 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
620 |
607 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
169 |
169 |
$2K |
| D2394 |
|
19 |
13 |
$1K |
| D1120 |
Prophylaxis - child |
68 |
68 |
$1K |
| D9210 |
|
109 |
93 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
165 |
146 |
$621.00 |
| D1206 |
Topical application of fluoride varnish |
52 |
52 |
$456.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
14 |
$455.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$330.00 |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$303.00 |
| D0330 |
Panoramic radiographic image |
31 |
31 |
$240.00 |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$222.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$90.00 |