| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
509 |
507 |
$29K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,135 |
1,240 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,348 |
1,328 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
606 |
606 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
154 |
63 |
$14K |
| D1120 |
Prophylaxis - child |
197 |
197 |
$10K |
| D1206 |
Topical application of fluoride varnish |
354 |
353 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
298 |
298 |
$8K |
| D0274 |
Bitewings - four radiographic images |
216 |
215 |
$8K |
| D0272 |
Bitewings - two radiographic images |
275 |
273 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
126 |
125 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
28 |
$5K |
| D2951 |
|
85 |
24 |
$2K |