| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
811 |
801 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
833 |
825 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
473 |
466 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,314 |
1,546 |
$22K |
| D0274 |
Bitewings - four radiographic images |
674 |
669 |
$14K |
| D1120 |
Prophylaxis - child |
293 |
288 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
694 |
665 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
530 |
521 |
$5K |
| D9430 |
|
138 |
121 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
20 |
12 |
$1K |
| D0350 |
|
29 |
14 |
$278.40 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$210.00 |