| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
830 |
817 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
868 |
854 |
$19K |
| D9110 |
|
425 |
408 |
$17K |
| D0274 |
Bitewings - four radiographic images |
396 |
389 |
$13K |
| D1120 |
Prophylaxis - child |
192 |
191 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
304 |
300 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
464 |
431 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
138 |
137 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
56 |
38 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
408 |
249 |
$5K |
| D0330 |
Panoramic radiographic image |
48 |
45 |
$3K |
| D2394 |
|
23 |
14 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$866.00 |