| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
311 |
306 |
$12K |
| D1206 |
Topical application of fluoride varnish |
371 |
365 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
31 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
188 |
184 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
89 |
85 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
124 |
124 |
$3K |
| D0274 |
Bitewings - four radiographic images |
148 |
147 |
$3K |
| D1999 |
|
173 |
152 |
$2K |
| D4355 |
|
16 |
14 |
$774.34 |
| D0220 |
Intraoral - periapical first radiographic image |
103 |
96 |
$705.66 |
| D0230 |
Intraoral - periapical each additional radiographic image |
69 |
42 |
$540.05 |