| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
638 |
631 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
383 |
382 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,272 |
1,095 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
907 |
904 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
177 |
177 |
$9K |
| D0274 |
Bitewings - four radiographic images |
295 |
293 |
$6K |
| D0350 |
|
446 |
177 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
68 |
68 |
$3K |
| D9430 |
|
71 |
69 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
14 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
21 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
54 |
54 |
$594.00 |