| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
728 |
728 |
$41K |
| D9110 |
|
1,113 |
1,112 |
$31K |
| D0220 |
Intraoral - periapical first radiographic image |
2,172 |
2,112 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
503 |
503 |
$15K |
| D0274 |
Bitewings - four radiographic images |
405 |
405 |
$11K |
| D0330 |
Panoramic radiographic image |
237 |
237 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
138 |
106 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
65 |
54 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
601 |
598 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
134 |
134 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
192 |
189 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$179.20 |