| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
438 |
437 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
505 |
504 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
289 |
288 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,148 |
1,140 |
$16K |
| D1120 |
Prophylaxis - child |
271 |
270 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
232 |
232 |
$11K |
| D0350 |
|
1,089 |
379 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,184 |
791 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
43 |
$4K |
| D9430 |
|
79 |
76 |
$3K |
| D1320 |
|
153 |
153 |
$2K |
| D0274 |
Bitewings - four radiographic images |
82 |
82 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
85 |
82 |
$1K |