| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
680 |
668 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
660 |
650 |
$38K |
| D0210 |
Intraoral - complete series of radiographic images |
543 |
534 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
386 |
109 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
358 |
355 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,058 |
1,054 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
423 |
326 |
$3K |
| D9430 |
|
74 |
74 |
$2K |
| D1120 |
Prophylaxis - child |
58 |
58 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
41 |
40 |
$864.00 |
| D0220 |
Intraoral - periapical first radiographic image |
36 |
36 |
$374.00 |