| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,816 |
1,813 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
1,767 |
1,762 |
$49K |
| D0274 |
Bitewings - four radiographic images |
1,047 |
1,047 |
$29K |
| D0350 |
|
1,162 |
1,162 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
201 |
201 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
419 |
417 |
$6K |
| D0330 |
Panoramic radiographic image |
76 |
76 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
114 |
114 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
12 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
63 |
63 |
$880.16 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$182.00 |