| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,293 |
1,292 |
$101K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,730 |
1,730 |
$101K |
| D0210 |
Intraoral - complete series of radiographic images |
1,649 |
1,649 |
$79K |
| D1206 |
Topical application of fluoride varnish |
1,534 |
1,530 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
307 |
182 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
251 |
171 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
242 |
242 |
$10K |
| D9430 |
|
334 |
305 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
652 |
571 |
$8K |
| D0350 |
|
843 |
376 |
$7K |
| D1120 |
Prophylaxis - child |
138 |
138 |
$5K |
| D0272 |
Bitewings - two radiographic images |
240 |
240 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$52.65 |